The possibility of change Transcript of an interview with Dr. James Orbinski The following is the complete transcript of a Mar. 7, 2008 phone interview conducted by Barbara Sibbald, Deputy Editor: News and Humanities, CMAJ, with Dr. James Orbinski, Assistant Professor, Political Science, and Family and Community Medicine, University of Toronto, Toronto, Ontario, and the author of An Imperfect Offering: Humanitarian Action in the 21 st Century (CMAJ 2008;178:1192). He is also the focus of the documentary, Triage: Dr. James Orbinski s Humanitarian Dilemma (CMAJ 2008;178:1191-2). CMAJ: Why did you write An Imperfect Offering? Orbinski: I wanted to, in a way, personalize a world that is often seen as being well beyond Canada and the West, something that is outside of us and away from us. I wanted to write in a way that wasn t purely biomedical or political, but that was a very personal entry into a world that exists in a way that requires a different way of seeing now. I didn t want to write for academics, I didn t want to write simply for doctors or aid workers, I wanted to write for the general public so they could see the world that I ve seen and see it in a very personal way and understand that in fact it s their world as well. CMAJ: What was your aim in doing that? Orbinski: I m hoping that the reader will become more engaged in their world and become more active as citizens and also as people who support humanitarian activity. My hope is that people will become more engaged and more responsible for the world that is now literally theirs and that, hopefully, they can now see in a more clear and obvious way. CMAJ: Do you have a different message for doctors? Orbinski: It s similar. I think the access points are slightly different in that a health care professional whether you re a doctor or a nurse, physiotherapist or lab technician or whatever health care professionals have a very particular skill set that is directed at the relief of suffering. The practice of clinical medicine or public health, for example, is a much more intimate knowing of the other. I would hope that health care professionals would be even clearer in their mind about the motivation and intent of their profession, and that it is very much directed toward relief of suffering and maximizing of health. That is the goal, the central goal of the health professions. CMAJ: You talk about the physician s role to witness and speak out. Does that apply to all physicians? Orbinski: It certainly applies to all health care professionals. And doctors certainly. CMAJ: How can Canadian health care workers have that sort of engagement?
ORBINSKI: For clinicians, where one sees impediments to access to health, for example, and where one sees patients not getting the health care they need, physicians have a responsibility to speak about that, and to speak about it in a public setting whether they are in Moose Jaw, Rwanda or Tuktoyaktuk, it doesn t matter. Yesterday there was an article about the State of Ohio which has now set up a lottery for people to get access to health care. There are 80 000 applicants. There are 600 000 people in Ohio who do not have health care insurance. Their political system has reduced the issue of access to health care to a lottery. That s what it has become. In my view we have the responsibility to elevate the issue of access to health care to something beyond that. I mean it s a fundamental political choice and it s a fundamental choice around how we see ourselves in relationship to others, and it s a fundamental choice in how we see the dignity of others. And as a physician and health care professional one has a very particular, intimate experience of the suffering of another person and of the pursuit of health of another person. And from that experience comes the responsibility to speak about what you know, and speak about how the dilemmas and questions that aren t addressed appropriately make suffering worse or make the pursuit of health more difficult. CMAJ: So physicians have a role above other citizens? ORBINSKI: Absolutely. No question. CMAJ: In the documentary your wife said that part of the reason for writing the book is to lessen your burden. Can you explain that? Orbinski: You d have to talk to her about that. (Laughs.) CMAJ: Do you have a burden that this book will help you to lessen? Orbinski: No, I wouldn t put it in those terms. I feel I have a responsibility to act and to speak about what I know. Writing this book and being the subject of this film is one way of meeting that responsibility. And for me there are others. I m involved in starting a PhD program in global health at the University of Toronto, and starting a PhD program in analysis of global change. Two very distinct programs there. I m involved in Dignitas International, a hybrid research NGO [non-governmental organization] focused on community-based care for people living with HIV. I continue to be involved in the Drugs for Neglected Diseases Initiative [DNDi], which is described in the book, and on and on and on. And my research very much focuses on global health issues. So these are ways for me to meet my responsibility given what I know, and the book and the film are part of that as well. CMAJ: As I was watching the documentary, Triage: Dr. James Orbinski s Humanitarian Dilemma, I was thinking how unusual it was do a film about writing a book. Why did you choose to do a documentary about writing the book? Orbinski: I m not the producer, nor am I the director and I didn t choose the narrative device, if you will. That would be a very good question to bring to Patrick [Reed the director]. CMAJ: In the documentary you talk about how your emotions come from a place of silence. How by naming it, you lose it. Do you feel you manage to articulate those feelings in a meaningful way in the book and film?
Orbinski: I haven t talked to enough people who have seen the film or read the book, and I think I could only answer that after seeing how people react. I tried. And I m happy with the effort. We ll see how successful or not it is. CMAJ: Has bearing witness and being part of these events [e.g., the genocide in Rwanda] changed you, and if so how? Orbinski: I think it s made me realize how central politics is to both medicine and humanitarianism. Both exist in a political context. You can describe medicine and humanitarianism as apolitical, you can describe them as neutral, you can describe them as beyond and outside of politics, but fundamentally they exist in a political context and I think that is absolutely clear to me. CMAJ: So humanitarian organizations have to be politically neutral and, at the same time, the most political of animals. I guess that s what you re talking about. You can t be seen to be aligned one way or another. Orbinski: Under very specific circumstances, that s absolutely true. And in certain other circumstances, for example war crimes or crimes against humanity or genocide, there s no such thing as neutrality, there should be no such thing as moral neutrality in those circumstances. In those circumstances there are violations of the laws of war and the laws that are themselves determined politically. So if you are going to speak against violations of law, you are engaging in a political act by definition because you re demanding that the law be enforced. And in situations of war crimes, crimes against humanity and genocide, in my mind silence is virtually criminal. So you must speak in those circumstances. CMAJ: Your involvement has changed your intellectual response; has it also changed you as a person, in the beliefs you hold, or the way you behave in the world, the way you respond to the world? Orbinski: I don t see those [two levels of response] as different things. I see them as very much the same. CMAJ: Something Gretchen [Roedde, the author of the book review in CMAJ] was wondering about, because she has to cope with it, is how you make the transition from working in places like Rwanda or the Congo, to coming back to your wife and your children that reverse cultural shock. How do you cope with that? Orbinski: It gets less difficult every time. And the more one works internationally the more normal it becomes. In the same way that, for example, the more a physician works in the emergency room and sees all kinds of very, very difficult circumstances, to put it euphemistically, the more normal it becomes and the more integrated, if you will, in his or her daily life it becomes. And you go home after your shift and see your family. CMAJ: Do you become numb to it? Orbinski: There s a risk that that can happen. For me, I do not now work actively in war zones. CMAJ: Was that a conscious decision on your part?
Orbinski: Very much, because I have other responsibilities now, I have 2 young children, soon to be 3. Those responsibilities preclude taking certain risks at this point in time. And to me it s very simple, very clear, there s no dilemma or debate about it. And I work though Dignitas International and some other activities. I work largely around HIV/AIDS and infectious disease in the developing world. Drug development is another area of activity in the developing world. And those choices are consistent, if you will, with my current responsibilities. CMAJ: Do you think you might go back into the war zones later in your life? Orbinski: I m not drawn to war. For me the preoccupation has been medical humanitarianism and that s what I m drawn to in its many forms and I ll just keep doing what I ve been doing. We ll see where my experience and where the next experience brings me. CMAJ: How do you keep yourself motivated for this tough work? Orbinski: I know what the world can look like if people don t do this kind of work. I know what genocide looks like. I know what a famine looks like. I know what watching a country spiral into anarchy, and watching it exist in a state of collapse for 2 decades I know what that looks like. I know what epidemics of cholera and extensively drug-resistant tuberculosis I know exactly what they look like. So to not work is to accept that, and I don t accept that. And I know also what s possible, and I know that by working in a particular way it is possible to make things better. The DNDi, Drugs for Neglected Diseases Initiative, is a perfect example of that. The [MSF] Access to Medicines campaign is a perfect example of that. Three million people have access to antiretrovirals because of that campaign. Three million people are alive now because of that campaign and millions more will also gain access to care. And the whole issue of health care infrastructure, and global health and the possibility of changing global health, all of those have emerged as real questions, with real possible viable solutions because of that campaign and similar activities in other campaigns by people who have literally worked to make things better. I know what the alternatives are, and I ve made my choice. CMAJ: You seemed very discouraged when you came back from Rwanda and your father was the one who told you to pick yourself up and start walking again. Do you ever feel that sort of discouragement now about things that you see? Orbinski: Let me put it to you this way: If one was not profoundly disturbed and profoundly unbalanced after having witnessed the genocide there would be something wrong with you as a human being. And I think the same can be said, to a lesser degree, about other issues internationally. Obviously, I m a human being like 6.8 billion others and I have feelings and reactions to difficult circumstances. But I m also capable of choices and I m very privileged in that I m free to make choices, and I make my choices. CMAJ: But to see the depths to which human beings can sink in their depravity and their indifference to one another it must be extraordinarily difficult to shake yourself off and keep going. Orbinski: It s not easy. But again, I think the fact is that I know what the choice of doing nothing means, and I know what that will look like. And I also know that is possible through very careful action and careful choices to improve the world and make things better. And given those two alternatives, I choose the latter.
CMAJ: In the documentary, when you went back to the Democratic Republic of the Congo, you found that so little had changed in a lot of ways, and yet, there you are saying: yeah, well it s worth it. I guess that s what you re saying here. Orbinski: Yes. And if you ask, for example, how people in Somalia, the 100 000 people who in a 3 to 4 month period we treated and literally saved [from dying], if you ask them, was it worth it. What s their answer going to be? Of course it s going to be yes. And it s my answer too. Certainly the broad political circumstances are very difficult and they haven t changed appreciably, but for those people, the action matters. And it also creates, again, a possibility of something better. CMAJ: In the documentary you talk about how working in a place like Rwanda demanded a complete presence and an unclouded mind, and yet you found that wasn t always possible. You mention that 1 patient in particular, that young woman who had been cut up and raped, and your reaction to that, how you turned away and threw-up. It was just so poignant to hear you talk about that, because I think that a lot of people see doctors as being technically, scientifically perfect beings. And I think a lot of doctors see themselves as that as well. But there is that human element. So how do you let that human element in to what you do as a doctor? Orbinski: It should be your starting point. One has to, in a sense, keep one foot there, but then move, with the other foot, to some sense of objectivity and detachment, to bring to bear in a careful, reasoned way what it is that you know, and your skill. That s your responsibility. That s what you re there to do: to apply knowledge in a very particular way. If you apply it without an appreciation of the personal nature of its meaning for your patient, then you fail as a doctor, I think. And equally, if you keep both feet in that deeply personal starting point and fail to apply your knowledge and your skill to the needs of your patient, then you also fail as a doctor. So the challenge is to be rooted in your starting point, to stay there with one foot, and move with the other into a space of objectivity where you can apply your knowledge and skill. And it s not easy. CMAJ: I think it s something a lot of physicians grapple with. Orbinski: Yes. And in that particular circumstance that you referred to in the film, I was overwhelmed by her suffering because I realized what it meant for her, and for the entire country. It was just so overwhelming. CMAJ: It was sort of emblematic of what was happening? Orbinski: Well, yes. And on that day there were literally hundreds of other patients laid out in the street around the hospital. We were doing surgery on the street. And there was that kind of suffering across the entire country. CMAJ: Did going back there physically bring all these feelings back? Orbinski: I ve been back many, many, many times. But Rwanda for me is a special place in the sense that it was the most penetrating experience of my life. To be present in the midst of a genocide is penetrating, I don t know how else to put it. CMAJ: Would you describe your actions and the actions of other physicians at that time as being heroic?
Orbinski: I really have difficulty with the idea that choosing to be a decent human being is somehow heroic. I don t think it s heroic at all. I think it s normal. It should be normal. CMAJ: And that brings me back to the day-to-day life of physicians and other health care professionals and what they can do. You mentioned that they should be present and to speak out for their patients and their patients needs, in terms of access to care and so on. Are there other sorts of things that they can do outside the boundaries of their country, in the developing world, without having to leave their families and those responsibilities? Orbinski: It s important to be informed and aware of some of the dominant issues in global health. And today one of the biggest dominant issues is brain drain. CMAJ: Poaching? Orbinski: Exactly. CMAJ: You talked about Malawi in one of your speeches and how there are more Malawi trained doctors working outside that country than inside it. Orbinski: Exactly. In Canada and the US, Continental Europe, Australia and New Zealand, between 24% and 28% of doctors are foreign-trained medical graduates. And of that 24% to 28%, 75 % come from countries like Malawi. The fact is that today in Malawi there are 100 doctors for 12 million people. I think that s a crucial issue. Consideration of that issue should affect how we structure our human resource policy in Canada around health care needs and health care professionals, nurses, doctors and others. It should also inform our understanding of the emergence and re-emergence of infectious diseases. And how, for example, the lack of health care workers, the lack of health care infrastructure in the developing world is contributing substantially to the re-emergence of major infectious diseases and the emergence of new infectious diseases, like, for example, extensively drug-resistant tuberculosis. I think that for health care professionals, in addition to everything else they need to be aware of, which is a lot, having some appreciation of global health issues and at least the dominate issues, is important to their own thinking and their own participation in their own health care systems and the politics around those health care systems. CMAJ: So you re basically saying that physicians should get politically involved. They should tell their professional organizations: we ve got to have policies, we ve got to do something, you ve got to lobby and make sure that we have enough supply internally so we aren t poaching. Orbinski: Exactly. And also there s another issue, which is demand. It s not simply a question of supply it s a demand issue as well. Perhaps some of the demand put on physicians is excessive and unwarranted. It is unnecessary, for example, for a physician to take a blood pressure and to treat a blood pressure. It s unnecessary for a physician to do annual health exams. Physician assistants and, more importantly, nurse practitioners can do much of this basic primary health care. And the expectation among the general public that they are not satisfied until they see a doctor, is unrealistic given the cost and given the availability of human resources. It s a supply and a demand issue. CMAJ: Thank you so much for giving us your time. Orbinski: It s been my pleasure.