The possibility of change ========================= * Barbara Sibbald, BJ * © 2008 Canadian Medical Association Dr. James Orbinski's humanitarian drive has taken him from the board rooms of the World Health Organization to the Rwandan genocide, from co-founding Médecins Sans Frontières Canada (1991) to accepting the Nobel Peace Prize as Médecins Sans Frontières' international president (1999). Now, the Canadian physician has written *An Imperfect Offering* and is the subject of *Triage*, a new documentary film (see pages [1191](http://www.cmaj.ca/lookup/volpage/178/1191?iss=9) and [1192](http://www.cmaj.ca/lookup/volpage/178/1192?iss=9)) about his engagement with the developing world for more than 16 years. Orbinski believes this engagement is a medical responsibility. As he said at the CMA Leadership conference in 2005: “Medicine is first and last about our response to the dignity of other human beings and by extension about social justice. The centrality of human dignity lies in our relationship to each other. Health is a human right and it is our responsibility to hold government responsible. These are ideas that can be profound forces, more powerful than armies.” ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/178/9/1189/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/178/9/1189/F1) Dr. James Orbinski (right) examines a patient with gunshot wound at the Baidoa Hospital in Somalia. Image by: Steve Simon Orbinski has consistently led by example. After co-founding Médecins Sans Frontières Canada and working with the organization in places such as Rwanda, Somalia, Zaire, Afghanistan and Peru, he launched the Drugs for Neglected Diseases Initiative (DNDi) in 2003, a global not-for-profit research and development initiative. He also co-founded Dignitas International, which focuses on improving the lives of people living with HIV in the developing world, places like Malawi where nearly a million children have been orphaned by HIV/AIDS. Orbinski is a research scientist at Toronto's St. Michael's Hospital and an assistant professor of both Political Science and Family and Community Medicine at the University of Toronto, where he is helping to start doctoral programs in both global health and the analysis of global change. “Humanitarianism is an attainable ideal, it's the starting point. It is our responsibility as citizens, as human beings and doctors to speak out, to witness authentically to the reality of the political failures. The only crime, in my view, is the crime of indifference, silence and forgetting.” *CMAJ*'s Deputy Editor, News and Humanities Barbara Sibbald spoke to Dr. Orbinski about his new book, the documentary and his passion for humanitarianism. (The full text is available online at [www.cmaj.ca/cgi/content/full/178/9/1189/DC1](http://www.cmaj.ca/cgi/content/full/178/9/1189/DC1).) ***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. … 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. … 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 responsible for the world that is now 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 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:*** How can Canadian health care workers have that sort of engagement? **Orbinski:** For clinicians, where one sees impediments to access to health … 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. … 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 … how we see the dignity of others. the suffering of another person and of the pursuit of health of another person. ***CMAJ:*** So physicians have a role above other citizens? **Orbinski:** Absolutely. No question. ***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 of political of animals. They 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 … moral neutrality. 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 violation 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:*** How do you keep yourself motivated for this tough work? ![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/178/9/1189/F2.medium.gif) [Figure2](http://www.cmaj.ca/content/178/9/1189/F2) Dr. James Orbinski (left) with Emmanuel Murangira, a survivor of Murambi massacre, in Gikongoro, Rwanda. Image by: Steve Simon **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. … So, to not work, is to accept that, and I don't accept that. And I know also … that by working in a particular way it is possible to make things better. The Drugs for Neglected Diseases Initiative, is a perfect example of that. The [Médecins Sans Frontières] Campaign for Access to Essential Medicines is a perfect example of that. Three million people have access to antiretrovirals because of that campaign. 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…. I know what … the choice of doing nothing means. 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 2 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 were saying: yeah, well it's worth it. I guess that's what you're saying here. **Orbinski:** Yes. And if you ask, for example, 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.