A Doctor Without Borders: James Orbinski

By Metta Spencer | 1997-03-01 12:00:00

JAMES ORBINSKI: MSF works in 71 countries. At any one time there are about 700 expatriates and 10,000 national staff working in the developing world. Every year there are more and more "Complex Humanitarian Emergencies"-the Rwandas, Somalias, former Yugoslavias-and more "silent emergencies" such as Sudan, Tajikistan, Angola and Sierra Leone. Silent chronic emergencies are not a focal point of global media attention. They account for about 70 percent of all MSF projects. That's where most of the money goes. Other programs include long term development projects like surgical training and sexually transmitted disease programs.

But in the last five years the nature of humanitarianism has changed drastically. Civilian populations are now legitimate targets in war. It is now, de facto, a legitimate act of war to force a population to starve or migrate, and to deny them basic humanitarian services.

METTA SPENCER: I don't think many people see it as legitimate to starve a population to death.

ORBINSKI: Just look at what's actually happening. Zaire, for example, is a complex humanitarian emergency that's not over. In October of '96, a rebel movement attacked refugee camps along the Rwanda-Zaire border where the Interyhamwe and XFAR were also present. Interyhamwe is the former militia of Rwanda and XFAR is the former army. Together, they killed approximately 1.1 million Tutsis in 1994, and then joined the refugee camps along with Hutu refugees and virtually held the refugee population hostage-to get humanitarian assistance from the international community, sell it on the black market, and buy arms with which to re-attack Rwanda. Zaire's rebels, with the support of Rwanda, began to attack these camps to eliminate the threat of XFAR and Interyhamwe. That caused the refugee crisis we all saw on TV in October. Prime Minister Chrétien offered military leadership for a multinational force, and there was public support for the intervention. However, when push came to shove, outside military forces didn't want to intervene because they would have to use force to disarm the Interyhamwe and XFAR.

Some of the refugee population-less than half-were freed and crossed the border into Rwanda. The humanitarian agencies, including the U.N.High Commission on Refugees (UNHCR) insisted that at least half a million refugees had been forced westward into Zaire, and were caught in the cross-fire between the Interyhamwe, XFAR, and the rebels. Humanitarian agencies still don't have access to them because of the ongoing fighting. Intervention is still necessary. But the international community, knowing that this population exists in inhuman conditions, did not intervene. Silent acquiescence is a de-facto legitimization of forced migration and starvation as an act of war.

SPENCER: But the international community said there was no need to intervene.

ORBINSKI: I say there was, and is, a need. Just today an official of the UNHCR reached one of the the areas inside Zaire where we said the refugees were. He declares that the refugees are there, and that the international community should be ashamed of having abandoned them. Most children under five have died of starvation during the last 12 weeks. There's no will to support humanitarianism.

Another example is in Rwanda in 1994. The UN had full knowledge, months before, that genocide was being planned. When it started, the only thing other countries did was send in troops to extract their expatriates. The U.N. Security Council even pulled out UNAMIR, the peacekeeping force that was present.

SPENCER: The first time I saw you was at Harbourfront in 1993 when you and General Lewis Mackenzie discussed the role of the U.N. in protecting humanitarian workers. You said they should stop doing that. I was astonished when he agreed with you. After all, it had been his idea in the first place to use his troops to keep the Sarajevo airport open for humanitarian deliveries.

ORBINSKI: I was trying to distinguish the work of a humanitarian worker (such as the delivery of food, medicine, or water) from the work of a soldier. Mixing military action with humanitarian service confuses the population to whom the services are being offered, as well as the warring parties. You don't send a priest or a soldier to do a doctor's job. A doctor is a doctor. A priest is a priest. A soldier is a soldier. Perceptions of humanitarian workers have changed over the last five years. Aid work has become more dangerous. In Chechnya at Christmas, six Red Cross workers were assassinated. In Rwanda, three weeks ago, three Médecins du monde doctors were killed. Aid workers have lost their veil of neutrality and impartiality.

SPENCER: Was it just a veil? Surely there are humanitarian workers who genuinely are apolitical and don't take sides.

ORBINSKI: Is it possible to be impartial in a war? I think not. It's naive to believe that you can deliver humanitarian service without any impact on the dynamics of a war. This is now recognized. If I want to set up a hospital on the other side of the front line, you won't like that if you're trying to kill people on that other side. You will think our service to them constitutes a risk to you. If so, you will try to get rid of us or keep us from setting up that hospital. You may use assassination or covert methods, such as hir- ing someone to rob or rape my staff.

Humanitarian assistance provides a massive infusion of money, life-saving devices, jobs, and links to the outside world, which influence the conflict politically, socially, economically, and morally. It's naive to call this neutral or impartial. I'm not saying that one must declare allegiance to either side. One must never do that. But it is impossible not to affect the dynamics that surround conflict. And sometimes one sees acts of war that are beyond acceptability as defined by the Geneva Conventions. In such circumstances, one cannot stand by.

SPENCER: The Canadian government has decided to emphasize civilian peace-building. How does that connect with the role of aid workers?

ORBINSKI: If you look at war and what we can do about it, there's a couple of options. One is to offer humanitarian assistance, but this type of intervention doesn't deal with root causes. Over the last few years, with the rising number of conflicts, humanitarian assistance has, in many cases, become band-aids for bullet wounds. It's not stopping the bleeding and it's not dealing with the causative factors. Many intrastate conflicts can be attributed to the failure of civil institutional structures to resolve conflict. If we are going to prevent warfare we have to support the evolution of other mechanisms of problem-solving, specifically by supporting civil society and systems of good governance.

SPENCER: How can we export good governance? Or should we even do so? Some people think it's arrogant of us to put pressure on other governments to become democratic.

ORBINSKI: Well, peace-building focuses on supporting good governance and civil society's mechanisms. Canadian foreign policy has taken this up as one of its major thrusts and I enthusiastically endorse it. It's appropriate for our government to do.

SPENCER: That will create roles for civilian Canadians to help build institutions abroad.

ORBINSKI: Right. But it is difficult to operationalize and define systems of good governance and civil society in clear, measurable terms. Both governance and civil mechanisms need to be nurtured and supported in their evolution. In Canada, even though we have more than a few blemishes, we have good institutions and skill in civil society. Levels of tolerance and respect for the rule of law are high here. We should share this.

SPENCER: Is there a role for Canadian civilians abroad where atrocities are taking place? I've heard it said that in Bosnia, the best preventive would have been lots of foreigners with camcorders present and watching, able to report what they saw.

ORBINSKI: You have to be careful. I certainly wouldn't advocate bringing in foreigners with camcorders unless they understood the political implications of taking footage of an active war. But where there is social instability, one of the best ways to re-establish stability is to introduce human rights monitors-expatriates who are versed in the standards of basic human rights and are capable of documenting human rights abuses and advocating formally on such matters. Foreign eyes deter human rights abuses, just as a civil community is the strongest deterrent to crime. In any society where civility is at risk, the important goal is to raise and reaffirm it. In Rwanda, after the genocide for example, the country was flooded with foreign aid workers and human rights monitors. Their prescence actually prevented large-scale reprisal killings of the Interyhamwe and XFAR who had perpetuated the genocide.

The down side of this is the risk. Five monitors were killed in northwest Rwanda two weeks ago precisely because they were foreign eyes. Interyhamwe and XFAR who returned to that area with Hutu refugees want to continue the conflict, and the Rwandan military want to stop them. It is not clear who actually killed the monitors or the three doctors I mentioned earlier. So, yes, by being there in large numbers, you potentially raise the level of civility-but not without risk.

The level of risk varies a great deal, depending on where you are. At this moment, there is less risk to a human rights monitor in Haiti than to one in the Kivu region of Zaire, where massacres are taking place every day. Those committing the massacres don't want monitors there. It is in this kind of situation that the U.N. and foreign governments can use political, diplomatic and other forms of pressure to insist that human rights monitors and aid workers are protected.

SPENCER: Have you ever been in a situation of having to speak up about some atrocity?

ORBINSKI: There are circumstances-as in Rwanda-where the scale of atrocity is so great that it is impossible not to speak out. I was head of mission for MSF in Kigali during the genocide in '94. Kigali was the epicenter of the genocide where thousands of Tutsi and Hutu moderates were being killed. We tried to provide safe havens and advocated publicly for the world to intervene militarily to stop the genocide. In Somalia, where starvation and anarchy threatened a nation, NGOs provided humanitarian assistance and safe havens, and called for U.N. intervention. This led to Operation Restore Hope, which stabilized the situation for a while but then became a political and military quagmire for the U.S. and the people of Somalia, as well as a nightmare for humanitarian agencies.

In most cases the right thing for humanitarian agencies to do is engage in "quiet diplomacy"-talk unofficially to those responsible for atrocities. In other cases, they may unofficially request other NGOs or diplomats in the country to apply pressure. These are the most effective methods of stopping atrocities. Or one can unofficially suggest that human rights monitoring NGOs visit the region. Or one can inform international journalists, who can then corroborate the story without mentioning the agency or risking its staff. Or one may take the official route-go to embassies present in the country or to international governance bodies. If these fail, one may resort to international public advocacy. The higher up the ladder of options you go, the greater the risk to your program and your personnel. The people most at risk are the national staff. The expatriates are at risk, too, but when an expatriate is killed there will be consequences. And if your mission is cancelled, the atrocities continue and the people you were serving are no longer served. But the more you wait to take the next step, the more people may suffer atrocities. The political context is about balancing interests.

SPENCER: So you have called for military intervention.

ORBINSKI: Yes, but that's the last resort. And the U.N. and its member states may ignore the call, or respond only partially, with a weak or unclear mandate, as in Somalia, Rwanda, and now Zaire. The major limitation is the issue of state sovereignty.

SPENCER: In such dilemmas, I suppose you sometimes discover your own limitations as a human being.

ORBINSKI: True. A human being in a moral quandary may or may not be willing to take life-threatening risks when it is not clear that those risks will make a difference to people who are suffering or dying.The ever-present challenge is to remain hopeful, which is very difficult indeed. To achieve it, one must see all parties to conflict-victims, perpetrators, and those who watch from the sidelines-as human beings. Hope in another's capacity to be human can actually help him re-achieve this. This is what humanitarianism is all about. It is simple, yet very difficult.

While in medical school, James Orbinski worked in Rwanda for 18 months studying HIV infection in children. After finishing his degree, he wanted to continue doing development work and started the Canadian branch of Médecins sans frontières (MSF) with Dr. Richard Heinzel and Jim Lane in 1990. With the end of the Cold War, the organization grew exponentially, beyond their wildest expectations. Today MSF Canada sends out 75 nurses, doctors, water and sanitation experts, and logistics technicians each year to join its overseas operations.
Orbinski has worked in many crises-in Peru in 1992 during the cholera epidemic; in Somalia in 1992-93 during the famine, civil war, and anarchy; in 1994 in the Khyber Pass of Afghanistan with 150,000 refugees who had walked there from Kabul. Later in '94 he was Head of Mission in Rwanda during the genocide and war. When we talked in Toronto on February 3, he had just returned from Zaire, where he had been Head of Mission in Goma for MSF's emergency program.