An Imperfect Offering

An Imperfect Offering
Author: James Orbinski


The author’s explicit objective in writing this thrilling and inspiring book on humanitarian medicine is to explore ‘a way to confront unjust human suffering in the world as it is’. The book reflects the author’s long and varied experience of humanitarian work, initially in the field, and later as president of the foremost medical humanitarian organisation – Medecins San Frontieres (MSF). The narrative also mirrors his vision of humanitarianism as the relief of ‘the immediacy of suffering…most especially of suffering alone‘, and as ‘the struggle to create the space to be human‘. The biographical account reflects the diversity of skills and qualities that enabled the author to face the daunting challenges of global humanitarian work – from advocacy for neglected diseases, to dealing with the leaderships of ‘hot zones‘ such as Sudan, Chechnya, and North Korea. If there is a single key lesson the author sought to convey in the book, it is to stress the heavy responsibility doctors have ‘to speak out‘ in the face of humanitarian challenges (pages 7-11).

More suffering. Thomas Hawk on Flickr.


At the heart of the book are the deeply-held moral values which fashioned the author’s empathic commitment to humanitarian causes. These are rooted in his early life understanding of the effects of prejudice against Jews, and in his family’s experience of the ‘anti-Irish sentiments that were still prevalent in England at the time’ – a bigotry that forced his family to migrate to Canada. His empathy was also stirred by the touching images he saw as a boy of the Ethiopian famine – scenes which left him with enduring emotional scars. His sense of moral obligation to those who suffer was further concretised by his lifelong discussions with Brother Benedict, the monk who served as a sort of moral compass for him at all times, and who guided his exploration of troubling ethical questions such the relationship of humanitarianism and politics. Symbolic of his high moral ideals is the reason he proffered for studying medicine: ‘I wanted to be able to live in the world so that I could live with myself. I wanted to do something practical to relieve the suffering of others, while at the same time striving to understand the circumstances of such suffering’. He epitomised his ethical principles when he said ‘as a humanitarian, I can act from a feeling of shared vulnerability with the victims of preventable suffering. I have a responsibility to bear witness publicly to the plight of those I seek to assist and to insist on independent humanitarian action and respect for international humanitarian law‘. His goal-directed vision of humanitarian work is also reflected in his conviction that ‘as a citizen, I can assume responsibility for the public works – the world of politics – not as a spectator, but as a participant who engages and shapes it’ (pages 21-32, 127 and 392).

Ethiopian famine. Cliff on Flickr.

The largely autobiographical book focuses on the author’s life-long and deeply held commitment to global humanitarian assistance. In recalling his varied experiences in this field, the author depicts the practical aspects of his field work just as graphically as he portrayed the risks and horrors that accompany them. Just as he painted a realistic picture of the perilous atmosphere of the places he visited, he also conveyed a vivid sense of the history and culture of the people he encountered. This was the case, for example, when he documented his precarious mission to Somalia where millions were ‘on the verge of starvation‘, and where aid work was threatened by ‘competing clan militias and gangs that looted, raped, murdered and pillaged‘. It was also evident in his depiction of his mission to Afghanistan, a country that had been ravaged by years of Soviet occupation and a CIA proxy war, and where humanitarian work was threatened by civil war, ‘fighting among the nine mujahideen factions’, and an opium trade controlled by ‘arms dealers and warlords‘. Similarly, his eloquent description of his mission in Zaire was of a country where ‘between four and five hundred thousand refugees…seem to have been airbrushed from history’ – many apparent victims of ‘a massive revenge‘. Some portrayals were however of the positive cultural backgrounds of the people caught up in conflict; this was evident for example when he saw ‘thousands of Afghan refugees local boys and bearded men in gurtas and hats, and a few women in hijabs or head-to-ankle burkas, mingled with goats, shrouded tribal peoples, hawkers and traders’, and when he characterised Jalalabad as a town ‘teeming with cars, donkey carts and pedestrians who moved slowly along treeless narrow roads and alleyways‘ (pages 72-81, 137-138, 271-279, 142- 145).

GOZARAH, Afghanistan. ResolutSupportMedia on Flickr.

The author’s most defining humanitarian undertaking was undoubtedly his arduous experience in Rwanda, a country where simmering ethnic tensions between the Hutus and Tutsis had descended into full blown genocide. He documented the historical precedents to the crisis, tracing it back to Belgian colonial rule under King Leopold under whose barbarous reign the country’s resources were usurped, its population mutilated, and ‘more than 10 million people – half the population – were killed or died’. The author also chronicled the rise to power of Juvenal Habyarimana, a Hutu who, with the support France, seized power in a coup in 1973 – an event that triggered the massacre of about 20,000 Tutsis, and the migration of more than 300,000 to Zaire and Uganda. He described the carnage as a low-tech genocide which was carried out with clubs and machetes‘, and as ‘the most efficient genocide of the twentieth century’ in which one million Tutsis were ‘exterminated‘. He depicted his Rwandan experience as his ‘undoing‘ because it revealed to him ‘the fullness of what we are capable of as human beings’. As the head of mission in Rwanda, he led a surgical team, opened up a new hospital, and investigated the fate of refugees. His account made for gruesome reading as it depicted people whose hands and feet had been cut off and who were left to bleed to death in graves; bloated bodies floating in rivers; pools of blood on the roads; corpses in the gutters; and ‘the stench of death everywhere’ (pages 37, 41-44, 53, 58, 163-164, 170, 180-183).

Rwanda Genocide Memorial. Cofigmanager on Flickr.

The psychological toll of humanitarian work was understandably a major theme of the book, and in exploring this, the author described his unrelenting emotionally draining work in various conflict zones. For example, the ‘unspeakable‘ and ‘unbearable‘ brutality in Rwanda made him wonder ‘how much longer I could keep going’. Consumed by the horrors of that country, he said ‘I could feel indifference creeping into me…I was tired beyond what I thought I could bear any longer. I felt beaten by the waves of suffering, of killing, of screams, of silent stares, and waves of not just political indifference but malfeasance‘. The emotional burden of his experiences was also evident when he narrated his experience in Somalia, a place where ‘the smell and death and darkness were too much’, and where he learnt of such horrific stories as that of a man whose wife was ‘raped, shot in the face and stuffed in a well with four of their children (pages 119, 163-164, 234 and 98).

Rwandan genocide. Gil Sepereau on Flickr.

The author’s account of the history and work of MSF featured quite prominently throughout the book. In tracing the origin of the organisation, the author described how it was founded in 1971 by the merger of two groups of doctors led respectively by Raymond Borel and Bernard Kouchner. He explained that the vision was to establish a humanitarian organisation which will be independent of governments, and how this arose from Kouchner’s experience of the Biafran war when he was part of the Red Cross whose neutrality clause prohibited him from publicising his perception, since disproven, that the Nigerian government was pursuing a genocidal agenda. The book also recounted the internal rifts in MSF which led to the ousting of Kouchner. In describing the mission work of MSF, the author explored several activities including the treatment of diseases such as diarrhoea and cancrum oris; the performance of urgent surgery such as insertion of chest tubes; and preventative programmes such as measles vaccination and cholera prevention. He also reviewed the diplomatic dimension of MSF activities, for example the negotiations with local leaders which enable the field work to proceed unhindered, and its public advocacy work which resists political decisions that threaten humanitarian work (pages 68-71, 89, 109-110, 140, 95, 149, 158, 86, 116,17 and 193).

MSF Ballon. Ciaran Laval on Flickr.


With a greatly focused and chronological narrative, this account of humanitarian work is graphic and comprehensive, and it is symbolises the highest ideals of medicine. With clear prose, the author brings the reader into the conflict zones and refugee camps that are the theatres of humanitarian work. The book also conveys the harrowing sights and the intense emotions that define working in conflict areas and disaster zones. The author portrays not just the clinical work that is at the centre of humanitarianism, but also the diplomatic and management skills on which the success of the field work relies. The book also highlights the inspiring dedication, commitment, bravery, and sacrifice that define all those who participate in risky humanitarian field activities. 

Overall assessment

Apart from highlighting the causes and consequences of the conflicts and disasters that are largely ignored by mainstream medicine, this book demonstrates how doctors can make a difference when they exert concerted efforts and hold themselves and others to high moral and ethical standards. The stories in the book are as revealing as they are distressing, but they go a long way to stress the reality of healthcare outside of usual medical practice. The book is an important reference for global health, and I recommend it to all doctors.

Book details

Publisher, Place, Year: Rider, London, 2008
Number of chapters: 10
Number of pages: 431
ISBN: 978-1-84-604102-0
Star rating: 5
Price: £11.65

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