Lancet: A Meditation on Evil
Since a group of French doctors and journalists formed Médecins sans frontières in 1971, the organization has established a reputation for activism as well as humanitarianism. MSF has provided medical assistance in more than 80 countries and served in some of the worst flash points of the globe: Afghanistan, Congo, Somalia, Rwanda and Sierra Leone.
For a decade, there has been a healthy Canadian MSF contingent. One of its leaders is Dr. James Orbinski, 39, of Montreal, a founding member of the Canadian section. Currently president of the international council, Orbinski accepted the Nobel Peace Prize of 1999 on behalf of MSF.
"We are not sure that words can always save lives, but we know that silence certainly can kill," Orbinski said in his Nobel lecture in Oslo, Norway, on Dec. 10, 1999.
In recent weeks, Toronto physician Dr. James Paupst has done extensive interviews with Orbinski and several of his Canadian MSF colleagues, including Paupst's own daughter, Millie. He also talked to Toronto's Dr. Paul Spiegel, 34, who joined MSF in 1991 and whose observations about war and mortality in Kosovo appear in the current issue of the British medical journal, The Lancet.
Below, Paupst presents the conclusions of his discussions with MSF physicians:
MSF has become the exemplar of humanitarian aid because of the strength of its advocacy for victims who are unable to speak out against crushing bureaucracy and political systems that rule by terror and fear. The nurses and doctors share a noble vision. Leanne Olson, a 36-year-old nurse from Winnipeg, said of her MSF commitment: "We chose the greatest adventure we could because we wanted to make the greatest difference we could." Olson knows whereof she speaks. She joined MSF and went to Liberia in 1993, treating children suffering from the ravages of famine. Later, she served in Bosnia, Burundi, Zaire (now the Republic of the Congo) and Angola. She is now on a new mission in Congo. Like many MSF workers, she has pondered what causes men to commit atrocities. "I still don't know," she says. "In many situations those who are poor admire power, and are afraid of it. Their only source of information comes from those in power. While I was in Bosnia, a slaughter took place in a village 25 km away from where I was. Most of the people hadn't heard of it, and those that did, didn't believe it. This is how rigidly information is controlled. Predators intuitively know how to control information and distort the truth."
In 1992, Paul Spiegel, then 26, was on the Kenyan border with Sudan. He was the only doctor there when Sudanese death squads drove more than 25,000 refugees into Kenya. Half of the refugees were children without parents. These minors began to trade their food rations for Coca-Cola, cigarettes and sweets. "Neither I, nor anyone else around me, realized the consequences," Spiegel says. "Some months later, some unaccompanied minors came into the hospital limping and complaining of joint pain. Some had loud heart murmurs; their lungs were full of fluid. I diagnosed scurvy and beriberi -- two diseases I never thought I would ever see in my lifetime -- and treated them with a cocktail of vitamin C and B1. They improved almost instantly. It took me many years to recover from that first refugee experience, and I don't think I will truly ever be the same. But perhaps that's not so bad."
This experience led Spiegel to specialize in the medicine of catastrophe. He acquired a master's degree in public health from Johns Hopkins University in Baltimore, where he is now a senior associate. He is now one of the world's experts on displaced persons and refugee camps; in the last two years, Spiegel and his colleagues have worked in and studied more than 50 refugee camps. As an epidemiologist, Spiegel also works in the International Emergency and Refugee Health Branch of the Centers for Disease Control and Prevention in Atlanta. An epidemiologist is concerned with the incidence and distribution of disease and other factors relating to health. In fact, Spiegel is more than that -- he has acted as one of God's spies, responsible for giving testimony against the ultimate form of human censorship: "ethnic cleansing." In the current issue of The Lancet, Spiegel writes that "the targeting of civilians in modern warfare has become an objective of war. The pattern of human-rights abuses termed ethnic cleansing may include individual and mass killings, sporadic and systematic rape, the destruction of civilian residences and institutions, and often the violation of medical neutrality."
Dr. James Orbinski, president of MSF's international council, was in Rwanda in 1994, when members of the majority Hutus were conducting their campaign of violence against the minority Tutsis. "We were in an area divided into opposing war zones," he says, "and learned that there were Tutsi children in an orphanage and they were about to be slaughtered. I wanted to bring these children to our hospital. I asked the commander of the killing squad if he had children. He said that he had four but he had moved them out of the country." As for those in the orphanage? Orbinski remembers the commander saying, "These are not children. They are prisoners of war. They are insects and we will crush them." By the next day, most of the children had been slaughtered. "This is how people commit atrocity," Orbinski says. "The first step is to dehumanize the victim. Our imperative is to create a strong humanitarian space that acknowledges the humanity of 'the other.' One of our liabilities is that the humanitarian movement may for a time provide an alibi for political inaction. Doctors can't stop genocide."
Spiegel claims that 90 per cent of casualties of the war in Kosovo were civilian, and that older men were more than three times as likely to die of war-related trauma as men of fighting age. "My driver in Kosovo was a reserved and taciturn Albanian Kosovar physician," he says. "Two months earlier, he had to identify his uncle from a mass grave. His uncle had been tortured. His bones were broken, he had cuts all over his body and his penis had been cut off." In their Lancet article, Spiegel and his CDC colleague, Dr. Peter Salama, a 30-year-old Australian, stress: "Serbian forces may have targeted elderly males, who are traditionally the heads of households, in order to weaken the social and cultural integrity of the Kosovar Albanian society, to encourage abandonment by the family of their land, or to decrease the likelihood of relatives returning from neighbouring countries to care for them when the conflict ended. The targeting of elderly men represents a new facet of 'ethnic cleansing' that to our knowledge has not been well documented previously."
Why do we commit atrocity? Man is supposed to be special. Only he works towards the future. His elitism is derived both from the mystery of his origin, and an intellectual curiosity so avid that it imparts to him the ability to regard himself as a separate entity in relation to the world. This objectivity is what gives man his apparent invincibility and his ability to conquer. He has always been stimulated to gain information from his environment. His competitive force, which is both potent and compelling, leads him to his destiny. It's an exquisite irony that this destiny for some means cruelty, brutality and atrocity. In 1990, when the World Health Organization ranked which conditions contributed the most to the global burden of disease, war was 16th. By 2020, with the frequency of civil conflicts increasing, the WHO says war will be in eighth place. Spiegel reported that the proportion of all civilian war casualties has increased from approximately 14 per cent in the First World War to 67 per cent in the Second World War, and to 90 per cent in the 1990s.
Millie Paupst, 38, my daughter and a fellow in psychiatry at Duke University in North Carolina, was with MSF in Liberia during 1992. She has vivid images, sometimes approaching flashbacks, of her experience. "We were in a bush hospital," she recalls. "The area was surrounded by rebels. In order to take the critically ill to the larger centre of Monrovia, we had to pass through checkpoints controlled by these rebels. We were often fired at, detained for money or food. What still bothers me is that mothers of newborn infants would rub mud on the stump where the umbilical cord had been cut. They did this to make the stump dry up, but the mud often contained tetanus and these babies died in convulsive agony. One haunting memory was that often children would die with their faces disfigured by a grin of bitter irony [known clinically as risus sardonicus]. I don't think that when we returned to Amsterdam there was one person who did not experience post-traumatic stress."
Toronto emergency-room physician Dr. Michael Schull, 36, is now president of MSF Canada. His missions: Northern Iraq, Bangladesh, Burundi and Rwanda. "Each has changed me. I learned to discipline myself by knowing that wherever I am, I am practising medicine. In Africa, it's primordial medicine without sophisticated hardware. I may treat a child for meningitis and after that child has been cured, I know that his chance of survival is tenuous. But at least this crisis has been met, and a chance has been created."
When the political dynamic between East and West changed, a vacuum was created in which the political players lost interest in the developing countries. "We want them back in the game," Schull says. "That's our thrust and one of the ways of doing it is to play upon the conscience of the pharmaceutical industry." One major concern held by MSF is the way global pharmaceutical firms have stopped making medications needed in the Third World. There is a need, says Orbinski, "to steer 'Big Pharma' from the path of commercial avarice to what its responsibilities should ethically be. Lifesaving drugs for developing countries are not part of their corporate marketing plan."
The very marrow of MSF is its autonomy, its advocacy and its freedom from political influence. This was certainly on display during Orbinski's Nobel lecture. When he spoke of how "the dignity of the excluded is assaulted daily," the message reverberated throughout the world. "Humanitarian action," Orbinski said, "is more than simple generosity, simple charity. It aims to build spaces of normalcy in the midst of what is profoundly abnormal." Existence by its very nature should allow a human being to be a free agent responsible for his or her own development by acts of will. This is what MSF is trying to restore, a system of international ethics, and that is heroic.
Dr. James Paupst is a Toronto general practitioner and he is currently writing Eccentricity: The Pursuit of Bliss.