Grand Challenges (text from a speech at 2012′s Globe and Mail festival)
(note, i am more reliably posting at “jamesmaskalyk.com”. note 2. even that is quite unreliable)
I started write about Grand Challenges in the park at the same time as the voice of a man, yelling at himself, angry at himself, was carried to me on the wind, and I thought: that’s one.
My name is James Maskalyk, and for the next 20 minutes, I am going to try and keep it together. Makes you nervous this kind of thing, but there’s one thing you learn early in medical training, if you panic, do it on the inside. So far so good, right? Practice makes practiced.
This is a talk about practice. One of mine is emergency medicine, among other things, and that’s why I am here. That, and I worked in Sudan and wrote a book about it. You all know a war is happening there, right? Our newest country, our newest conflict. Another Grand Challenge.
The book I wrote about Sudan is about a war that has never really left, that drew the air out of the small town I worked in like a forest fire would. It takes a lot of energy to feed a war, large amounts of fear and hatred, and it takes great courage to stand weaponless before it. Some of my friends are doing that right now, Sudanese and not. They are there, in the middle. They are brave. They change the world.
Do I? Maybe by standing with them. Do I by standing here, telling stories from far away? Possibly, but less so. Stories can only get you so far, no matter how full of action.
A Semantics professor, Irving Lee, held up a matchbox at the beginning of his semester, and asked his students: What is this? Eventually someone said “Matchbox”, and he would throw it at them and say “Matchbox is just a NOISE”. So are these words leaving my mouth, and no matter how well I put them together, no matter how sweet the sound of a sentence that offers sincere help, nothing will ever beat the hand that pulls you up. All the talk about Sudan, and places like it, pales against the people struggling in the mud.
That said, it is my sincere pleasure to be here, in front of you. When I get a chance to do these talks, I am thrilled, because the dialogue moves me closer to an abiding answer about how to live more authentically. I am also mystified. How is this on anyone’s radar? From what I’ve seen, working in places that need the most help is fairly lonely business. It is what makes the readjustment so jarring. Where were you guys? Maybe you just like the stories.
I’ve been a curious witness, watching the story of health evolve over the past 15 years since I stepped off the plane in Santiago, Chile, into a vastly different landscape of sickness and disease than the one I was trained for. I worked there, in the public health system where people tried to pay for their grandfather’s surgery with a dozen mastercards that they borrowed from their neighbours, and the poor, well they just died, and I realized that if I could look forward to any societal status as a physician in Canada, it was because I took care of the sick ones, no matter where, and no matter when. The sickest, though, by all accounts, seemed to be in other places. I decided to go to them.
How could they be so sick? A curiosity became an interest, a focus then a career, and I watched international health change to global health as schoolchildren understood the world as an ecosystem in a way that my zoology professors struggled to explain. Economists, geneticists, apiarists alike have clearly detailed interdependence at all levels, and show us that nothing is immune to what ails one part of an intricate and complex system, nothing separate from it, not even us, and in that sense, we are in this together, like it or not, and the question how to do the best we can with what we have, is an increasingly vital one, because our connection to the war in Sudan, and places like it, is not esoteric nor academic, it is important because it directly involves you. Because of that, noone is free from war until all of us are.
Though this may be my belief alone, I believe we are seeking something, each of us, in every sentence and every action, buzz around it like moths do a bright light. How honest we are with what we are looking for is how close we come to finding it. I believe, what we seek, is freedom from the ties that bind, that stop us from connecting fully with the source of all things, from letting love pass through fully, fearlessly. For me, that is what the Grandest Challenges speaks to. Framed in the language of health and the body, it is why we want to be well. Though the work is often at the level of particular diseases, it must also be at the barriers that stand in the way of people doing it for themselves, at the injustices that let the suffering of so many serve the purpose of a privileged few, holds them from joining their ranks as surely as their malaria does sick in bed.
The largest example of this, for me, is in war. My first taste of it was as a brand new doctor, working with a recently surrendered group of Khmer Rouge in the south of Cambodia. On the conditions of their surrender, after 25 years of fighting, they had been given a hectare of land, deep in the jungle, to carve into rice fields. They were starving and malarious. I arrived to this valley, home to these many people and a dam, built at gunpoint during the war, that claimed the lives of hundreds during its construction, and stopped one kilometre short of completion. With a borrowed land cruiser and a borrowed translator, my intent was to do a month’s worth of medical clinics in the morning and spend the afternoons meeting with village elders to find out their challenges.
My first afternoon, there was a party for my arrival. Women hurried back and forth between steaming pots and a table set under a large bamboo house, high on sticks. As I sat to eat, we saw a rooster tail of dust from an approaching truck. It slowed, and the driver stuck his head out the window and yelled something in Khmer. My translator turned to me and said “they want to know if you want to see the woman now, or if you will start tomorrow.” I set my bowl down, and walked to the back of the vehicle. In the box was a woman, old for that place, 60 or so, with a fever, barely conscious, bleeding from her mouth and nose. I was terrified. “Tomorrow!”, I said with a certainty I didn’t have, “Take her to the hospital!”, and we sat down to a meal these people could not afford, and one short day of reprieve.
I learned a lot that month, about war and sickness, how to take care of as many people as possible with the resources at hand. My medical kit, full of borrowed antibiotics and equipment, as big as a refrigerator, dwindled down the size of a lunch pail, full of only a few essential medicines. I am still learning. It is why we call it practice.
To do as much as we can with the tools at hand for as many people as possible, that is the grand challenge, and that is what we must focus on. William James says, take the simplest case of sensorial attention, trying to keep your gaze on a dot on the wall. Soon you will find one of two things has happened, either the dot has become blurry or indistinct, or your mind has been called to other things. However, if you ask yourself successive questions about the dot, how big it is, what color, how far away, you can keep your attention on it for a comparatively long time. This is what genius does, in whose hands an idea coruscates and grows.
This is the question that we must meditate on, to roll over and over again in one’s mind, how to do the best with what we have at hand. We are part of a time when society has turned from religion to science and its inventions to deliver us from evil, to medical science to deliver us from suffering. Because of the promise, people sat in my waiting room the other night, beside that man angry at yelling at himself, or make trips over hot miles in Sudan on a faith that medicine can deliver us from uncertainty, though anyone who is a student of research will tell you that what we don’t know far eclipses what we do, that what we learn most from studies is how flawed our methods are at approximating the truth.
What is the faith in, then? I would say that it spreads from the sacred space between a doctor and a patient, one that is inviolable and beyond undeclared interests, that happens when I close the curtain or gesture towards the somali woman sitting underneath the thin shade of a tree with ten others, and say, “Hi, my name is james, I’m from Canada. How can i help you”, then let nothing stand in my way from doing that. Medicine as an example of life caring for itself.
The same cannot be said about the question when asked by a foreign government, or a foreign investor, because no matter how important the welfare of the suffering person in front of them, their interests can only ever tie with the competing ones, and often finishes a very distant 2nd. For that reason, I am a bit more uncomfortable with placing industry as an important leader in our quest to solve these grandest challenges, and think of it is a necessary component, but as a follower, never the arbiter in deciding what counts as a common good. Rather than protect a promise from a business to deliver a magic bullet, or encourage them to do so, I would favor removing the barriers that prevent the distribution of ideas and local solutions from flourishing.
I would argue that in the business of health, to do the best we can with what we have at hand, we already know much of what we need to focus on, and like my medical kit in Cambodia, it doesn’t need to be full of fancy medicines or new equipment, but a small amount of essential tools and medicines, and a local system who is able to answer, and deliver on the sincerely asked question about how best to serve the person in front of them. The rest will follow, and until it does, it will sit heavy as unfinished business.
I spent the first half of this year in Dadaab, Kenya, the world’s largest refugee camp. My practice was focused in the feeding centre, and pediatrics ward. It was exacting, difficult work, for which I was well trained and had good experience for. Still, I was challenged. I saw things that I had never seen before. One child I cared for, his skin fell off, he was so malnourished. When you turned him, it crumpled like tissue paper on a wet windshield. I had never seen anything like it, couldn’t find anyone who had. I looked in books, on the web. No similar cases. Many challenges like this. When I arrived to Dadaab, we were getting 1000 people per week, by the time I left, 1000 per day were making the trip across Kenya’s dangerous border, arriving starved, some naked and raped. By the time I left, we had so many kids in the feeding centre, I couldn’t keep track of them all, scattered in tents, the dusty yard.
It was a difficult place to find respite. And dangerous. The risk, primarily, was kidnapping and because of it, on our way to the field, we were asked for a sample of handwriting, to give answers to questions that only we would know, so we could prove, if we were taken, that we were still alive. We lived in a compound, and went about our work, and never mentioned it, in fact, I would say we didn’t even think about it.
One night, after tossing and turning in bed, I feel asleep. Deep in the night, I woke to shouting. My first thought was: “this is it….Shabaab’s come for me”. I rolled out of bed, swiftly grabbed what I thought I would need for my months in captivity. Passport, money, iPod, iPod charger. The essentials. I pulled my window’s curtain aside and searched the courtyard for the sweeping flashlight beam of whatever guard sold me out.
Nothing. Silence. The courtyard was empty. Then a cheer, like someone scored a penalty a kick, or missed it. Football. Champion’s league. A late game, and with the time change, the middle of the night. I lay back down, and my heart eventually quieted.
Though I would have said I wasn’t even thinking about the danger, in fact, I was thinking about it ALL the time. It was right there, at the top of my subconscious, filtering everything that went deeper, or came up through it. It coated every nuance of my experience, and I believe that is true of these grand challenges, the images of suffering, of the bombs dropping in Sudan, the starving people in Somalia, nuclear weapons sitting silent in their silos, the man yelling at himself on the street. Even though you cross over to the other side, it doesn’t matter. It sits there, as unfinished work, and though you will never be able to accomplish it all, there is no other solution but to start.
Sadly, for two of my colleagues who were working on it, who followed me in Dadaab, they fell to the risks inherent with working so close to the suffering, and were kidnapped. Two women. From Spain. They are still missing, presumed to be in Southern Somalia. Two months later, around last Christmas, two more MSF’ers were collateral in this dangerous turn, and killed in Mogadishu. I mourn them, even though we’ve never met.
They didn’t make these risks. It was done by those who fostered distrust for people in white landcruisers as part of larger political, economic, or religious agenda, who had one hand extended with food, and the other calling in the drones, that made us look disingenuous and expendable.
Despite these risks, or because they are ours to share , we are still in Dadaab, and I would bet you that today, even on a Saturday, that people are hovering over maps and figuring out how we can get safely back into Mogadishu, because matchbox is just a noise and trying to get rid of war with fighting is like trying to clean something with dirt.
People know this, feel this. It is why on April 21, I didn’t wake up to Kony posters. You can’t change the world by liking something on facebook. A click changes the world a click’s amount. Right now, my co-director of the Ethiopian program is on a plane there, our 6th month in two years, to live beside, work beside, and show solidarity with Ethiopian doctors, share their weight of trying to do the best they can for the person in front of them with the tools they have. No orator, however eloquent, no video campaign however sincere, can match the power of guiding someone’s hand on an ultrasound probe until they get the right picture, or while they deliver their first baby. Worthwhile work is difficult, and long. It takes years to build trust, seconds to lose it. One drone. We need to involve as many capable hands as possible, such that our existing tools can attain their true worth, and in these hands, corruscate and grow.
I work in Ethiopia to work myself out of a job. Who better to care for victims of a famine, or do research about the most efficient way to distribute resources than the people for whom it is a daily reality. Try as we might to place ourselves, as great as our capacity for empathy is, as sophisticated as our tools of approximation are, it is no substitute for proximity.
We should share our tools and peripheralize as much knowledge as possible so this can happen as quickly as possible, because by many accounts, not only are people dying early, of preventable things in unacceptable numbers, but we are exerting such pressure on our ecosystem that we need to, as quickly as possible, learn to live peacefully, cleanly, and efficiently together before we face even grander challenges.
What could be grander than the ones we have right now? What about “Holy frack, where did our water go?”, or “it spreads like SARS, but it lasts like HIV”. Future historians might not talk about our age as “the digital age”, but the “age of antibiotics”. I am overemphasizing none of these possibilities.
I was working for a medical journal when SARS hit, and I watched the response carefully. At its worst, people were fighting for recognition in petty academic wars with stakes so small they were invisible. At its most hopeful, people shared ideas in a way only possible in our modern world.
The challenges will continue, and we need to remove as many barriers that prevent us from sharing the best of what we’ve learned efficiently and effectively. I look forward to the time when we lose the energy that that surrounds protecting proprietary ideas, and devote it to their efficient delivery.
It is why, out of all the projects that I am involved in, the one that has the greatest potential for this is Open Medicine. Not only can you get the science free of cost and undeclared bias and industry influence, you can have the software that we use to publish it. The possibilities are enormous. Not just publishing the evolving results of a study that goes on forever, but also lectures, curricula. We are talking about an article where you can have the structure and format of how we teach emergency medicine in Addis, but also the presentations themselves, and with these, a videocast of our Ethiopian colleagues delivering the lecture for the 80% of the world where their medicine matters. For those who think that we will remain indefinitely at the apogee of privilege are poor students of history, those who don’t think that we need as many true friends as possible, blithe to human nature.
I see a day where Addis Ababa University is a destination for Somalis who want to learn emergency medicine, Sudanese, North and South, who want to share their ideas about how best to control outbreaks of meningitis. The faculty there will be the editors of an online wiki textbook, with many colleagues from around the world, about how best to address their common emergencies. Their research institute will collaborate with MSF-East Africa to make context appropriate guidelines for the care of starving children, using local foods and publish them in Open Medicine.
Open Medicine will be like Google, except that you won’t be able to buy product placement, only deserve it. Research, seminars, curricula, opinions, available to anyone who can get online, for free. Openmedicine.uk, or openmedicine.et, for their country’s guidelines, openmedicine.net to search them all. The governments of these nations, in an effort to do their job of representing the best interests of their citizens, and all people no matter where they live, will have demanded that all publicly funded studies, or of drugs and devices that will be adopted by national formularies, need to be published in Open Access journals. This will not only encourage innovations, but spread them as widely as possible, because there isn’t much time, and the best idea needs to win.
Are these solutions up to the grand challenge? No. Practice makes practiced, never perfect, only better. It is called the grandest challenge because it will always lie ahead, in the distance. There will be no grandest victory, only the struggle, of which each of you is part of whether you recognize your agency or not. While saving the world might not be possible, we can redeem the notion of what a human being is. The way to do that is by asking the questions sincerely, starting to work on the answer, and never giving up.