May 24, 2009
Thank you President Hill, for your warm and generous introduction, and to Professor John Feroe and the trustees for welcoming me yesterday. I want to thank the senior class officers and faculty advisors for your consideration and support in extending the invitation to speak today, and to the students who sat down with me yesterday to share your ideas, questions, and passions.
I am deeply honored to be standing here before you.
This "ultimate" Vassar Class of 2009 – congratulations for your achievement: the completion of your undergraduate studies from this exceptional institution of liberal arts and sciences. Many of the people here today around you have played a role in brining you toward this moment. Let us acknowledge your professors, guides, and teachers and their outstanding dedication to education and the Vassar community. And let us thank your parents, your deservedly proud, perhaps slightly relieved, and maybe just a bit anxious parents, and your brothers and sisters, your grandparents, your friends – they are around you and in you, and I want to say to all of you, congratulations.
So today we celebrate what you have accomplished, both in and out of the classroom, in your time here.
The ultimate graduating class of 2009! This, your final year at Vassar, has been an absolutely extraordinary year in which there was an invigoration of American civil society in the political process. Young men and women, you and your peers, participated in amazing numbers and unexpected ways. Whatever one's personal beliefs or personal political convictions, you demonstrated the power of your voice and your capacity for action.
I can't help but feel optimistic that what is waiting for you when you leave this amphitheater is filled with so much possibility. I want you to feel with your fingertips the rough edges of what is not yet – what you will shape and create and do.
I am going to talk to you about making choices, about holding and defending principles, and acting from those principles. And I want to see if I can open to you my sense of responsibility and the discovery that comes from living in-relation to others.
Ten years ago, early in my first mission with Doctors Without Borders, (known in the field by its French acronym MSF), at the southern edge of Khampa Tibet, part of Qinghai Province, China –a young man from a nearby village came to call us. Following him, with Nyima our interpreter, and Kunchok, driver turned registrar and vital-signs-taker, we came to a low mud brick home and ducked our heads to enter inside. On a straw bed in the corner was a woman, lying down, flushed and restless. I had seen her once before, I remembered, a visit where we gave her a very basic prenatal kit (to cut and sterilize the umbilical cord). Later we had now heard her labor was taking a long time, but nothing more. She had given birth, two days ago, but now there was another problem: the placenta had not come out.
What we are faced with is often something basic, the care of which we take for granted here in this country and many places. But a retained placenta is a route for infection – untreated; this can progress to sepsis, shock, and death. Kunchok told me later that a local woman had lost her life in this way, only two weeks before we arrived, when there was no one there who could help.
I knelt down, and with Nyima next to me explaining, and Kunchok sitting with her, we separated the placenta from the uterus wall, and eased it down and out.
MSF was in this remote rural community, because after having responded to two years of severe freezes and food shortages, our team could see that medical care had become practically non-existent, a population excluded, in this case a rural, ethnic minority, in a country being thrust toward urban development and a market-based economy. I was there because I had made the choice (to go where the needs are), and because I was there, I was able to perform this direct concrete act.
To choose to be there, to meet urgent or critical need with direct medial assistance – this is the core, the basic act of what we do as individuals in Doctors Without Borders.
The remarkable Juliette Fournot is one of these individuals who made the choice to be there, to help others. (Actually, in today's New York Times, there is a review of a graphic novel of her time in Afghanistan – it incorporates photographs, one of these is an old classic photo showing her in the mountains, in traditional mail dress, hand on reins, in a zigzagging convoy of men and mules going through the mountains.
In the early 1980s, aware of the terrible conditions for Afghan civilians during the Soviet invasion/occupation, Juliette was trying to find the way for MSF to help. She was rebuffed by Pakistani authorities, who wouldn't grant access to refugee camps where thousands of Afghans had gathered to escape the fighting. And the Soviet authorities refused entry through the capital Kabul. So Juliette decided that she would just have to walk in. She explains herself very matter-of-factly at an event the other day: "I had tried, and this is where the people and the patients were, so where we went." First a day, then a few days, a week, a month's of walking distance she led MSF teams across treacherous mountain terrain, providing medical care to injured children, women and men, and establishing valuable relationships with local communities. This then was the start of what became 20 years of MSF's assistance to the people of Afghanistan. It's incredible, thinking back, the capacity of an individual for choice and the possibility of what can result from that choice.
So in reflection, while preparing to speak to you today, I found a number of places in which my understanding of my experiences in the field with Doctors Without Borders (as well as my practice here at home) had language and shapes of ideas that had roots in my own college studies. (Most of which took place in classrooms that were quite far from the Science Hill part of campus.)
I remember philosophy professor Maurice Natanson (since passed away), his bushy white beard and a pocket-watch tucked into a tweed vest, who introduced me to the work of Emanuel Levinas.
Levinas was building on the works of phenomenologists, attempting to describe what is before us, what we can actually perceive – the meaning of what we see and feel, what we experience. He wrote that, "in the beginning was the human relation." What I think he suggests is that we exist fundamentally as social beings. Though I have been discussing individual choice and action, it is important to see the individual as "in-relation," to understand our sense of responsibility to others.
We are bound to one another, and in that can see the other in their suffering, in need, and it becomes obvious when we see that, compelling us to do what we can.
Many of you have already been choosing action. The Vassar Uganda Project, the result of a process that went from academics to insight, research to definite action, has given supplies and medicine, time and training for improving health in towns in southern Uganda. Closer to home, Operation Donation responds to poverty and the Vassar Prison Initiative confronts the impact of incarceration – two issues which, through my practice in the Tenderloin neighborhood of San Francisco and up at San Quentin State Prison, I have seen stubbornly and brutally persist in our community. There are many more such student groups and organizations, as well as individual students who exemplify dedication and energy and taking responsibility in this kind of relation with others.
Right now some 2200 international staff, and about 25,000 local/national staff (who come from inside the community or country in need) are working with Doctors Without Borders in more than 60 countries, coming together with a shared commitment to humanitarian action.
We are not only doctors, but also midwives and nurses, administrators, logisticians, water-sanitation experts, drivers (like Kunchok), hospital cooks and cleaners, and more. To be humanitarian is not a specialty, not a professional class, nor a certain course of study or training. It is instead members of civil society who choose to practice some core principles.
I would like to put before you three of these principles I've come to understand through my work with MSF, and describe their role and relevance in humanitarian action, and how they can sometimes be threatened or called into question.
They are bearing witness, valuing human lives equally, and independence.
Let's go back to the beginning of MSF that President Hill referred to. The Nigerian Civil War or Biafran War lasted from 1967-70 and was responsible for the deaths of more than a million people. The French Red Cross was working in hospitals and feeding centers in Biafra, and had in place the policy requiring workers to sign an agreement prohibiting public speech, in order to uphold the organization's neutrality.
But after experiencing attacks on medical facilities, targeting of civilians, and the widespread starvation and death, doctors returning to France broke ranks to publicly criticize both the Red Cross and the Nigerian government and brought media attention to the crisis.
It was felt at the time that a new organization was needed that would prioritize the welfare of victims over political boundaries and over religious or ethnic identity, and would speak out when this was violated. An organization that would maintain individual conscience in its association. Thus, in 1971, MSF was founded by a group of French doctors and medical journalists. Today, speaking out remains one of our very most important tenets and actions – we call it temoignage, bearing witness.
We've recently been speaking out about the same crisis that caused so many deaths in Biafra—malnutrition. I first treated acutely malnourished patients in Sierra Leone, in 2002, just after the end of 10 years of civil war. In the southern district of Moyamba, MSF had taken in charge the care of children, often the most vulnerable in a time of crisis, in the pediatric ward and the inpatient therapeutic feeding center. At the time we were using what was called therapeutic milk, a preparation of powder and water that needs careful measurement, and often needs to be given one spoonful at a time.
We have all seen these pictures of malnourished children, but it is different to be there, to follow the slow sure change from a listless and silent child and a mother stone-faced with resignation. In only a few days of treatment, sometimes a week—light returns to the eyes of both mother and child, the patient becomes stronger, then is sitting up, beginning to play, and the connection, the care in the bond between mother and child is found all over again.
At any time, about 20 million children are suffering from severe malnutrition. Since I left Sierra Leone, there is a new, incredibly effective treatment tool: What we call ready-to-use foods (sometimes called by a brand name, PlumpyNut). These are foil packets nutrient-rich, energy-dense food, a peanut-flavored milk-based paste that contains all of what the smallest children, those under two years old, must have for healthy growth and brain development. The packets can simply be handed over, a corner torn off, and eaten directly—not only are they effective but they can be used with patients—the children—at home with their families. With its ease of use and home-based treatment, obstacles to care are significantly reduced and the number of children that can be treated increases tremendously.
So MSF and its Campaign for Access to Essential Medicines has been speaking out to UNICEF and WHO, other aid organizations and local health authorities about this for the last few years—speaking and educating, publishing articles, and holding an international conference in New York.
WHO and UNICEF have adopted these new protocols for treatment of malnutrition including the ready-to-use foods, and many other organizations are getting on board. But despite this, others lag behind—the international food aid system is large and complex, and is connected to many political and economic issues. A developing country's image and reputation can be at stake, the effect on domestic food prices and markets, farm subsidies, all have their impact. The U.S. government itself has a huge potential role in this issue—it alone supplies 50% of food aid to developing countries, but for now that food still lacks animal-source protein, which is the key ingredient in ready to use foods. There is still much more to do until every child has the nutrition they need, and we will continue to speak out until they do.
In malnutrition, speaking out, bearing witness is really about valuing human lives equally, that children no matter where they are or what situation they are in, should get the food they need for growth and health.
Something called "Chagas disease" also brings this principle into focus. It is the 100-year anniversary this year of Dr. Chagas describing the disease, the organism, its transmissibility. In its chronic form, the parasite causes heart and intestinal disease, leading progressively to heart failure, disability, and death. It is endemic in many Latin American countries, (and more in the U.S., Europe, Australia and Japan due to migration). It takes the lives of about 15,000 people every year, and affects an estimated 14 million people in total; mostly the very poor as they are more likely exposed to the vector, a large insect that lives in the thatch used to build homes. The few medicines now used, even if used early, fail to get rid of the parasite, and in later stages we have almost nothing to offer, short of heart transplant for these patients. It is one of the most neglected diseases—internationally there is a complete lack among both public and private institutions, of research and development, funding, even basics of care and attention to patients with Chagas disease.
This neglect was understood just this past Monday, when the Member States of WHO announced they were cutting the 62nd World Health Assembly in half, including canceling all of their sessions on Chagas, "in view of a possible influenza pandemic".
When we choose to act, in relation, when we take responsibility for others, we have to value the lives of others equally as ourselves. No matter, as in Chagas disease, that the patients are poor, far away, unseen in the thatched huts of rural communities or having immigrated, are here in our community. These patients must be cared for and treated and not left alone any longer.
In Fall 2002, the conflict in Liberia again drove people to flee for their safety across the border into Sierra Leone. Two hours from the district hospital where we were working, the UNHCR transported them in trucks to Taiama, a largely abandoned camp formerly for the internally displaced. There was urgent need for food and shelter, adequate water, things like measles vaccination, effective treatment of malaria and other infectious diseases, and malnutrition.
The refugee camp was large, hot, with the trees long since cut down, and stick buildings clustered around small clearings for cooking and some semblance of community life, in other sections of the camp, only long transit tents, in thick rows, stripped of plastic sheeting, with sometimes 30 or 50 people trying to live inside. There was sometimes noise of play and community, also sadness and hunger, emotions of working to rebuild something familiar, something comfortable. Refugees are people who have lost, had taken away from them, essentially, their ability to choose (to choose where and how to live, how to eat, what to do)—this is one way to understand of the condition of those we think of as the very most vulnerable, when individual choice has been radically reduced to just surviving, to just getting through the day.
We built a clinic in Taiama camp, we treated patients, took them when needed (almost always children) to our hospital wards for inpatient feeding, for oxygen or blood transfusion, for artemisins or antibiotics.
We were not the only ones working to help the Liberian people—UNHCR granted them official refugee status, and Sierra Leone was well known by that time to aid agencies—in Taiama we took in charge the health care, but others were doing camp management, the water, education.
As the camp swelled in population without a concomitant increase in assistance, I went to the district's "interagency" working group meeting to described these stripped-bare transit tents, the wells that were dry, and the fact that there were now only two working latrines for 7,500 refugees. In this meeting I learned that of the 18 seats at the table, all but two (myself and an MSF coordinator who was from a camp to the east) were agencies under, or "implementing partners" of the UN, and that there would be no latrines until the end of the year or any other services added, because there was no more money.
At Doctors Without Borders, we do not depend on outside agencies (nor public institutions) for money, nor when it comes to deciding what to do. By securing support from civil society, independent support mostly from private individuals (more than 500,000 in the U.S. alone), we maintain an independence of means that is not susceptible to political priorities, or international decision-making that is out of our control. Independence is necessary, so we can ensure our ability to choose and to act, to give assistance when we see it is needed.
There are other areas in which the principles of independence, and the challenges to it, are more complex, as when aid is confused with political or military aims.
Over the last several years, there are many examples in which the understanding of what separates humanitarian assistance from political or military objectives has been muddied or outright rejected. Non-governmental organizations were described as "force multipliers," while an article in the Atlantic Monthly, said that the military, "is emerging as the world's most effective relief organization," and recommended "combined ops" and "training with civilian do-gooder groups."
Kenny Gluck, former Director of Operations for MSF, in contrast, said that: "Humanitarian assistance expresses human solidarity, and has no aim other than to alleviate the suffering of populations in need." Independence and impartiality are vital to the relevance and effectiveness of our actions, they are the tools that enable us to obtain the consent of belligerents and the trust of communities, correctly assess and understand needs, and shape our response. When humanitarian action or language is co-opted, our motivation comes under question, trust can erode, the safety of our staff in the field is put at risk, and our ability to help the people most exposed to violence, most in need of care, is jeopardized.
At the same time, I think that if leaders of non-profits, perceiving a government to be politically in line with their aims, or to have interest in developing similar assistance programs, if these non-profits decide to work in collaboration with or coordinated by that government, this independence is given up. I think we need to argue this point in our civil society—both to organizations and to our elected leaders. This is the risk under a "friendly" government, that the lines between humanitarian and political may be blurred, this critical perspective can be lost, and the humanitarian character of aid and the ability in the end to help those most in need can be compromised.
So present underneath these humanitarian principles, is the other part of bearing witness, the quiet part, the quality of being with:
As simple as a doctor being with a patient, sitting still and listening to his or her story, maybe a rare quality these days. Or a midwife, mit-wife, literally being with the mother. Or bringing food to someone who is hungry and sitting down together with them to eat. Or being with a friend in their struggle.
I want to read you a fragment from Kafka (of all people) called "At Night":
"…All around people are asleep. It's just play-acting, an innocent self-deception, that they sleep in houses, in safe beds, under a safe roof, stretched out or curled up on mattresses, in sheets, under blanket; in reality they have flocked together as they had once upon a time and again later in a deserted region, a camp in the open, a countless number of men, an army, a people, under a cold sky on cold earth, collapsed where once they had stood, forehead pressed on the arm, face to the ground, breathing quietly.
And you are watching, are one of the watchmen, you find the next one by brandishing a burning stick from the brushwood pile beside you. Why are you watching? Someone must watch, it is said. Someone must be there."
The way he describes, it could almost be people driven from their homes to a refugee camp, or it could really be us, our community, our civil society. For all the walls of structures and habits in our lives, we are "flocked" together and breathing together. It may be quiet, but we are exposed.
To me, the watchers recall our responsibility, but there is something else I notice too in this: firelight that is in their hands. We make individual choices, in relation with others, holding our principles, and I find that doing that leads to something else—a kind of illumination.
One more moment with Levinas. He describes in our face to face relation with the other, that sooner or later, in words or actions or a gaze (being with), the other surprises us, does something that we could not have known, could not have predicted. And in doing so, they overflow our sense of them. To me this tells us that we can fully choose, beyond what others think or how they see you or imagine you. The other in our relation founds us, illuminates our possibilities and ourselves.
I've experienced this in unlikely times and places some of which I've described to you:
Weaving between beds in the dark pediatric ward in Moyamba, an infant on my forearm, learning how I respond when a life is, literally, in my arms.
In the back room of addiction rehab at St. Anthony Farm, talking about drugs and shaving foot calluses, coming to know something about the deep difficulty and joy of personal change.
And years before in the driver's seat of the cargo van, the summer after freshman year at college, with "Joe" navigating. "Joe" found me when I came to work Fountain House, a mental health clubhouse program in New York City—he was schizophrenic, and maybe nothing is more Other than schizophrenia. His clanging speech crashed and dissembled between us, but together that summer, I felt and found the growth in me of a kind of recognition or understanding that didn't need language, and together we found our way.
Whether in work or school or in other parts of our lives, wherever we choose to act, we trace a path of relation and responsibility, going out from ourselves, that will ultimately lead us back in what I think are extraordinary, creative, and unpredictable ways to who we are.
I am incredibly humbled, having been able to do this work. I am grateful and astonished having been brought into the lives of my patients, their families and communities, just this quality of being with them.
I hope you find illumination—for now, to start, I suggest only this: take up the responsibility to bear witness to your relations with others, and to your own possibilities, and you will find a way. It will be amazing.
And enjoy the weekend. Congratulations! And thank you very much.