Mah-Skall-Ick

the spot warmed by grace has gone cold.

but just for now.

in my piassa apartment.  sun beams warm through a window, then a cloud.  partly cloudy is the best kind of weather because what’s not to like?

tree outside my window bursts from the ground.  if you were a mountain, you would be, like, whoa, so fast?  this place is out of control! the moon, watching the mountains crash like waves, then smooth, then crash again, would say, slow down, let me get my breath.  the sun…well, she would have better things to do than watch us.

busy at the hospital.  busier and busier all the time.  you build it…

a man had his leg taken off.  it was blue to the knee.   i saw him this morning, the day after, wincing in pain.  he looked better, somehow.  more himself.  he has a fever now.  i’m worried.  his remaining foot is not looking so good.  dusky.

today, as every day, on my way to the hospital, i walked past the coffin sellers that line churchill. i try not to take it personally.   beautiful swoops of gold weave on the red felt that covers people’s final box.  outside of one the shops, a father scooped last night’s injera onto his son’s plate.  father to son, cradle to grave, even these people, one day, in their beautiful boxes.

a shroud, my mom said to me, when i asked her how she wanted to be buried before i left, just a shroud. let the worm’s dig into me, straight away.  good idea, i said, changed my will from “a pine box, buried somewhere beautiful” to “shroud”.  she’s still teaching me, after all these years.

when i went away to cambodia for the first time, to do this kind of wore more than a decade ago, i made a CD on which i wrote “play in case of emergency: funeral mix”.    i like plans, what can i say. it’s a youtube playlist now. don’t get sad: the afterparty is more of a dance thing.  maybe you’ll get a chance to hear it if they can’t fill the part of my will that says “if technology allows, transplant my living head and brain, even temporarily, onto a giraffe’s body”.  i just think the galloping would be INSANE.

this afternoon i walked a group of visitors, ferenjis, foreigners through the emergency.  in the background,  a woman screamed, someone pushed a patient by, shroud over his face.

one of the women who was touring paused, turned to me “what is YOUR self-care plan?”.

work with what comes up, i guess.

the world might not be bad or good, but it does ask you certain questions. like: can you see through the lattice of self reflection straight into the outside where bird song takes up empty space in large gulps?  do you get that the only guarantee is that you are born to die, that it’s a matter of time before the other leg starts to look a little purplish too, and the living that happens between then and now, is in your hands, all of it, so how are you going to do it?  in the absence of answers, you can only live questions and the best one i’ve found, the most sincere and direct path towards disappearing completely, is to ask myself if i can give love, and only it, at all times, in every gesture, to myself, to everyone i encounter on this kaleidoscope merrygoround that i get ride for the time being, and perhaps even for a few glorious days galloping clumsily across the savannah, choking down bitter leaves.

i can’t.  i mean, with the love thing,  but i’m getting better, and there’s no perfect anyway, and even if there was, it would last, just change like everything.

at one point, when my practice was stronger than it is now, when i had done a few retreats  months apart, and sat every day for an hour so, first thing in the morning, after i woke, after I stood up from my cushion and winced at the slow electric  feeling in my leg, i would forget who i was.  it was weird.  i would look for glimpses, but there would just be pieces fluttering, disappearing as i tried to to pull them together. i could not even find where to start looking, so i would just hobble down the stairs.  by mid afternoon, the story of myself that i tell myself would form into a sense of “here” and “there”, but until then, there was no difference between the two.  my sense of suffering, during these months, was as close to zero as it had ever been, because there was no one to do it.

there is now.  i’ve a hangover. they have them here too, i was sad to learn.

the smell of a jubilee, once faint, grows stronger.

first here, then here, then here, then, on june29, toronto, here.   you should come.

as i look back on the last months, it’s tough to say i’m proud of anyone, as I have had nothing to do with making them.  still, daily, i feel something akin to that, when i watch the doctors we’ve trained navigate a floor full of sick and worried people with skill and compassion.  maybe it’s awe.  maybe that’s what pride was supposed to be in the first place: an awe one feels to participate in something beautiful.

here is their facebook page.  i like it.  actually, it’s more of a love thing.

one of them, anyway.

i’m finding it difficult to write. service seem to compete.  why would i spend my time talking about doing something, when there is so much doing to be done?

this morning, i walked down churchill road’s steep hill, the fine, metal smell of poorly scrubbed gasoline driving itself deeply into my smallest spaces.  beside me, cars honked, buses chugged, people fitted between and moved across the road.  at the bottom, there is a corner where people gather selling tea or fried bread to long lines of ethiopians queued outside the ministry of immigration.  three women pushed past me, smiling, carafes of tea steaming in their hands, and ran towards a busy bus that had stopped up the road. i promised myself, like I often do, that one day i’ll buy all the tea and all the bread, and they can go home early.

i entered the hospital gate, past teams of students in white coats, walking hand in hand, leaning on each other, laughing.  i waved at the ones that i knew, or stopped to do the shoulder bump that ethiopians have been doing since forever.  i drew close to the emergency, and heard the high wail of a woman.  i turned the corner, saw her facedown, in the gravel outside our one window.  she rose to her knees, then threw herself to the ground.  again.  her mother.  her father.  her sister.  her daughter.  who knows.  i was five minutes early, five minutes late.  abat, i said, and tapped the blue jacketed security guard on the shoulder.  he kept his eyes on the woman, and unlatched the emergency’s half door to let me pass. inside, the thick smell of sickness in still air.

we put an ultrasound on a young woman’s chest, and saw her heart swinging wildly in a bag of water. with great care, we guided a needle into it, through her diaphragm.  its metal glinted white on the screen.  when it was next to the collapsing muscle, the one through which all the love passes, we pulled bloody fluid into a syringe. her breathing eased. ours too.

a man died breathless.  his pupils widened into a final, unflinching stare, because there was no more use for the light.   there were no wails.  he was alone, found by the side of the road, bruised, maybe beaten, or hit by a car.  we worked on him for long minutes, hoping to get his heart to beat wildly too.  we could not. we didn’t say , after, that if we had better tools, things might be different, because we already know that. we scattered in separate directions, separate thoughts on the same thing.

better people, though, i can’t imagine.  i am humbled by them.  that is why i end up in places like this.   people think it’s because i am generous, but it’s more selfish than that. i come to be, in equal measures, as two sides of the same paper, humbled and inspired, because i would give my life for the idea, that if we make the world easier, even briefly, for someone, the illusion of our separation from them disappears.  i am giving it.  i have no questions.

well, maybe some.  tomorrow i want to ask these young doctors and nurses: how do you deal with all the dying?  there’s a fine line, you see, a balance that can tip.  when you see a lot of it, and then catch yourself in the mirror, your eye to your eye, you can say to yourself, when you’ve seen a lot of it, have just watched a young man’s electricity shake itself free, blink out just like that, you can think that you too are mostly dying, and forget about all the living.

a week ago, I was in the omo valley, running on a straight, rocky path, jumping over small puddles, edging along larger ones, scratched by brambles, my hands bleeding from the thorns.  on hot flat stretches, swatches of brand new butterflies, perched on some treasure in the soil, opened and and closed their new wings.   I ran through them,  and the rose, pattered against me, swirled and trailed in the wind, weightless,  thousands and thousands and thousands blinking points of light.  so much living.

i left the emergency, late for my lunch, ravenous for my lunch, and a young man stepped in front of me and said “my muzzer….my muzzer…”, and pointed at the building i’d stepped out of.  what about her, i said, and his eyes became wet, and the tears started to fall.  he had no more english.  take me to her, i said.

beside her bed, her breathing fast and shallow, i gently welcomed this man to the end of her days, mourned with him and his sister, then left them behind.

how do you deal with it, and still get on with all the living you have yet to do?  i’ll ask them tomorrow morning.

late for lunch l walked down the street.  people smiled, and held hands.  trees stretched an inch closer to the sun, in as many directions as they could.  a bird flew underneath the eaves of a building and was gone.   the world was clear and wide open.   behind me, somewhere in the building i left, on its upper floors, two people came out, wet and new, crying: how cold, how bright.

ajan chah used to hold up a glass and say, “this glass will one day be broken.  for me, though, it already is”.

write hard and clear about what hurts.  that’s what hemingway said, anyway.  i guess in that way, you could write about the whole, wide world.  sunsets, murmurations, those friends walking hand in hand, between these buildings, five floors below.

the other day, i sat to get my shoes shined, gray as they were from bole’s dust.  three young boys jostled to be the first at my feet. i  chose the one who had first raised his hopeful brow, mimed with his brush.  i pointed at one of the other boys and said in amharic “tomorrow”, to the other, “wednesday”.    today grinned, tapped the wooden box with his brush.  i set my foot on it, and watched the world go by.

the boys laughed with each other and tried to speak with me, until we were all  lost in the street scene .  taptap. one shoe done.  zap.  the laces flew out of my other.   a security guard appeared behind me, and tossed a sandal on the ground.  it’s strap was broken.  one of the boys, the one with the tuft of hair at his front (the style in addis, these days, particularly if the tuft is dyed blond), opened his wooden box and took an awl out, and a length of thick black thread.  he punched two holes in the sandals broken sole, pulled a loop of thread through with a small hook, another hole in the broken strap, tied it all together, and handed the shoe back.  the woman dropped a single birr on the ground, 6 cents, then turned.  the boy with the tuft of hair turned it over with the awl, disappointed, then put it in his pocket.

where i was from, i would have explained if I had the words, my friends would have, i mean, i would have, just thrown both shoes in the trash, and bought another pair.  the old ones would have been carried to the curb, then lifted into a large truck whose engine ran all the time, that drove to another, bigger truck, then from there to a place where even more powerful engines pushed mountains of broken shoes over each other, because noone knows how to fix them anymore or anyone who does, and for a rare blink of time, we can pretend that this doesn’t matter, we can as be ignorant of value as we are blind to the chugging boats carrying containers of plastic shoes from chugging factories to chugging trains are, like we are the growing piles of plastic shoes waiting their thousand year turn to dissolve into parts ready for another turn.

taptap on the wooden box.  two shoes done.  i paid twice the price.  as I walked down the long hill towards churchill road, blue mini-buses strained in the other direction, packed full.

i sat with the doctors and nurses who had helped during the difficult death of the young boy i spoke of last time. i tried to gather them just after, but the day was too full, too many patients on the ground or leaning on the backs of chairs, huffing.  tomorrow, then.  we need to talk about it.   not because anyone did anything wrong; the opposite.  we did the best we could, but we are pushed by that bright impulse to do it better, only ever better, never perfect, only practiced.  as importanlty, we need to be clear about what hurts, lest it turn into something else.    it’s ok to feel sadness when a young mother weeps over her son’s still frame.  it’s what we’re supposed to feel, and if we don’t, it’s because we’ve hidden it from ourselves.  but we’re in it together, with each other, with him, with her. it’s ok to mourn. let it come up, and through, bear it, let it do its work, and it goes.  ignore it, and fixes in your heart like gum, then hardens into anger, or unease, and fingers swing wildly at at each other, from the fulcrum of our own heavy heart.

in that small room, six of us mourned quietly for that young man, and his family, said some silent prayers, voiced some new ideas, and left it renewed.that you can transform suffering into compassion by being clear about it is one of the most wonderful gifts love has given us.

today is the anniversary of my grandmother’s death.  a year ago, i stood in front of a group of friends and family in lac la biche, alberta, snow piled high in the parking lot of the small church, the nearby lake, frozen hard, and talked hard and clear about what hurt.  i’ve been back there since to see my grandfather, and as i slowed to a stop in front of the kitchen window where she invariably stood, washing dishes, or cleaning carrots, an excuse to peer into the dark, watching for the jitter of my headlights on the gravel, it was empty, full only with the bare wall behind it.  like me, like you, like that boy, she was already broken. i walked in, and my grandfather was sitting quietly at the table.

“she always gave more away than she kept for herself.  not just her garden, but her love,” i  a said to my dad today, her son, as he stood framed by that same kitchen window,  talking in turns,  the millisecond delay familiar from all my times away.

“yeah…that’s it……”  he said, then paused into a long, thoughtful silence.  finally, wish you could be here.  me too, i said.  love you.  love you.  bye.  bye.

last week, thursday, lunch with someone from the ministry of health.   “we are ‘visioning”, he said, “for the next five years for the health system of Ethiopia.”  while I’m sure you have your own, given your deep knowledge of history and place, the context and resources, i’ll share mine, i said.  it’s this.  a young boy, from a wealthy family, is walking late at night home from a football match. he has no money in his pocket, no phone.  he left both on the kitchen table before he went out to play.  a car careens around the corner, and he moves to leap out of the way, but twists his leg on a stone, falls, and is hit.  the driver stops, horrified.  a crowd gathers.  “don’t move him!”, someone shouts, as the driver bends over to lift his crumpled frame.  an ambulance is called, and medics tape his broken neck to a spinal board, and take him to black lion emergency department, because it’s where people go when they are suddenly sick and don’t have any money, and at the door, they are met by doctors and nurses, who from the first minute  know exactly what to do.

we might be broken from the beginning, our hearts, perhaps even our bodies, but life has seen fit to create a system where it puts itself back together, at least temporarily, because it knows there is great work to be done by every single soul as it looks for the sweet release from what holds it back from connecting fully with what moves it.

speaking of sharing. i’ve finally found a connection that allowed me to get some new music.  like water, to a thirsty man.  got this record.  recommended. love.

Pulled the muslin gauze over the face of a fifteen year old boy, and walked away from the wails,  down the hospital’s dark halls to find some air.  In a doorway a woman with bright sequins on her hijab smiled at me, a beautiful baby on her hip.  Framed by a window, two lovers held hands, looking at the city that stretched below.   I put my hands on the sill beside them, and leaned out.  The air was sweet.

Welcome to the broken, beating heart of the world. Not Ethiopia, I mean, but the one inside this present moment.  Thing is, you can’t hold it back even if you try, so you let it in and it does its thing, breaks you down, brick by brick, until there is nothing left between you and it, and just then, at your most vulnerable, it surrenders itself to you in a sweet embrace, holds you in the perpetual centre, moves you, whispers “it will be ok, even death, even that. ” Maybe, if you’re lucky, even that whisper fades.  On that day: freedom.

I almost drowned once, or so I tell myself. Everyone has a story like this.   A current had given me access to part of the ocean I didn’t deserve, carried me out past the break into huge, rolling swells. I sat there on my board, watching them crash, rocked up and down like on an elevator.  I decided that they were too big, that I would wait for a reprieve, and paddle in on their wash. I turned around to watch the thin line of the horizon, and saw the crumble of a wave breaking behind me. In that white foam, doom. I turned my board broadside, the worst move, and was caught and dashed straight down. Every time I started to see brightness, my leash would rip me blacker. I couldn’t reach it to set my leg free. Breathe. Don’t breathe. Breathe. Don’t breathe. Like that. For long seconds, I didn’t know up. Finally, tumbling, I let myself go loose, and waited. Brightness. Gasping. Like everything, in that, a lesson. You can’t fight the ocean because as soon as you’re in it, you’re part of it, so roll.

That same ocean hammers on the tin above me. Between its thunder, I can hear faint music. Strings, a woman’s, then taptaptaptap.  A lull, and the song floats in, mixing perfectly with the weather until it picks up. Harmony.

I’ve arrived to Addis a day or two ago. On my first morning, I woke myself from a deep, dreamless sleep, blinking the heavy lids of jetlag. My body, familiar with the feeling from all the shifts and travel, made no complaint, and pushed itself up, and out the door.

I am staying on Addis’ most famous street, Bole road. It runs from the airport, to Meskel Square, a broad plaza where the best runners in the world start their mornings, zagging over the rows of bleachers that if run from end to end are exactly ten kilometres. I’ve passed them at the 5 in the morning (in a car), and they are not jogging, but running towards it at top speed, some barefoot, on black asphalt.

Not on Bole, though. It is torn to pieces. It is being rebuilt in preparation for the African Union’s 50^th anniversary in May. Like so much of this city, it is in construction. Cranes dangle on the city skyline. Train stations are being pushed together, rows of old houses pushed apart, replaced with ones with plumbing, electricity. This century is going to be Africa’s, and in no small part, Ethiopia’s. The anniversary is a nod to the past, but in this place, in this country, all eyes are on the future.

Mine too. It’s why I came. I’m here to work myself out of a job. Teach medicine well enough so it can be taught, then I just come home and relaaax.  Whatever that is.

I walked out into the morning sun and picked my way along the busted rock.  Ahead of me, a woman stepped deftly, wearing heels, boulder by boulder, bag balanced on her shoulder.   Her eyes stayed forward.  She didn’t teeter, not once.

That’s the city.  Not really my thing, or so i tell myself, but it’s where I often am.  I would rather be in the bush, i say. In Sudan, or the papaya orchard I called home in Cambodia. This is where the people are, though, and they are streaming here, fast, running towards the future.  With them, the young doctors who will pick them up when they fall and put them back together, the ones who will greet the centennial with grins, shakes of their gray head, “remember when…”.

Though some battles are being fought in the bush, I think it’s here where it will be won.

 

I’ll see the young doctors who will do it tomorrow at morning report. It gives them hope that I keep coming back, that I’m true to my word.  Of course, it’s them who inspire me. Though I don’t know if the future will grace them with the cover of Time magazine, to me, they are the most famous people in the world. Who else? Really? That guy? Riight.

Don’t think I’ll be here for centennial. Another 50 years? Maybe just. If I dial down the smoking (note, insurance companies: i have never smoked, and never will smoke…i use the smoking of cigarettes for their literary effect, you know, waving them, their bright light as an incandescent punctuation mark, like that). I’ll try.

The rain has slowed. It’s dusk. The mountains that ring Addis are black silhouettes against a purple sky. I can see Bole from my window. The part that has been tarred glistens, mirrors a man walking by with a newspaper over his head.

This song has come on. Thao. Girl be playing Toronto this month.  If you can, see that show for me. Cities are good like that.

I’ll do my best to blog. It’s not as easy as the bush, distracted as one can be from the broken, beating heart of the world by all of the flashing lights and moving pictures of the past. It’s here, though, same as there. Has to be. No other way. It’s the just the one ocean and all, same one that moves through the rivers and the clouds, you and me, back again, like love, and you’re just part of it until its done with you.

 

 

we throw these beautiful parties in toronto (and you should come), but because of my addis travels, i am away until the summer. in lieu of rocking the party with my soul brothers, i send this prayer to the celebration deities.  love.

I shot my brother in the eye with a gun.

He was seven, I was ten. I told the story to a psychiatrist I worked with, professionally, one busy day in our inner-city emergency department, the caterwaul of a confused, psychotic person behind us.

“I’m going to be nauseous for the rest of the day”, she said, and stood up.

I lived in the country, and had a little gun. An air rifle. With it, I was allowed to shoot only two things: targets and varmints. There were three forms of varmints in the fields where I lived: gophers, whose holes could break a horse’s leg, magpies who strewed garbage from our burning barrels all across the lawn, and moles, who blindly ate the roots in my mother’s garden. The latter, I didn’t shoot, but trapped in their dirt tunnels. They were the only ones I got paid for: a dollar each. It’s possible I never got permission to shoot the magpies, but I lumped them into the varmint category on my own after listening to their laughter, high in the trees, as I scooped up their slimy trash.

It didn’t take long for me to discover that what allowed me to discharge my responsibility as varmint sheriff was a puff of compressed air that pushed a lead pellet down the barrel. I emptied the gun, and saw the ripples it made in a puddle, then worked up the courage to hold my hand over it, wincing as I pulled the trigger. A discovery is best shared. A little brother, best experimented on.

I spent an hour convincing him to look down the barrel of the gun. I can’t recall my young logic. A test of trust. Bravery? Perhaps I even did it first. I don’t remember.

He bent over the rifle whose stock I had pumped three or four times, and put his face over the barrel.

I shot mostly soft, lead pellets. They were the most deadly, because on impact they spread so the hole they made was bigger. They had to be loaded one at a time though, so for targets I poured hard BB’s through a hole in the action.

I was sure the gun was empty. I’d tested it. I didn’t want to shoot my brother in the eye. Mom would take the gun away.

A bright, copper BB was stuck in the magnetic chamber, and when I set the gun on the ground, stock down, it clattered into the chamber. I didn’t hear it.

Sang Seuhn, a Korean zen master, says that the problem with the world is that there are too many people, and that we eat too much meat. The problem isn’t the diet, it’s the killing of so many animals without looking into their eyes. How can you know what you do, when you sit so far away from the weight of your actions? There is no exchange between the hunter and the hunted, where each recognizes that one day they will be on the other side of the equation.

I was having lunch in a small town in Cambodia, near where I worked with a starving group of Khmer Rouge. Next to me, a man sat with an AK-47 leaning against his table. A friend bumped his table, and the gun slid, clattered to the ground, the barrel facing me. Its owner smiled sheepishly and picked it back up. A week later, someone threw a grenade into that place. I went to the nearby hospital to help, and bodies were lined up, stiff, out the door.

“Penance,” a medical student said, when I told him the story about my brother, knowing where I worked. Yes, I answered. The other side of the equation.

Sudan bristled with guns when I was there. More are on the way. Libya had one of the largest stocks of light arms in the world, and after its recent civil war those weapons are now moving across its long borders into the hands of its neighbours.

One afternoon on an airstrip, I watched two young boys get beaten with a stick as they crawled on the hot ground using their elbows, dragging gun sized pieces of wood.

In Cambodia, a friend asked a Khmer Rouge commander how many men, women, and children lived in his valley. Ten thousand, he answered. And how many soldiers? Ten thousand.

America has created a viscous army for itself. Convince your people that it is not only their right to bear arms, but a duty, and then convince them there is something to fear. How many soldiers? One-hundred-and-fifty million. In Connecticut, people are counting their tiny graves.

A colleague of mine was once held hostage in our emergency department. A sniper’s rifle killed his captor. We rushed the hostage-taker to the trauma room and tried to save him, but failed. Snipers make few mistakes.

My grandfather makes bullets. He loads the powder in, grain by grain. He says they are more reliable than the ones from the store.

I nestled my rifle onto a coat that lay on the hood of my grandfather’s truck, and angled it towards a target in the woods. The crosshairs danced. Bang. The gun recoiled and the scope hit me in the forehead. I wiped away the trickle of blood before my grandfather could see. Bullseye. Later that day, I shot a deer through the eye. It fell like a stone. It’s blood steamed in the snow.

Guns. Since I was a young boy, they’ve occupied my daily thoughts. They are my default dream. The finality of their bang and a world transformed. The power. The powder. Each grain a plus sign in a deadly equation, giving us a velocity we don’t have the wisdom for, letting us live on the same borrowed time as the carbon we pull from the ground and use to light on fire. The power of gods, in the hands of children.

I pulled the trigger. Brother’s head bounced back and he fell. His hands flew to his face. My heart. My god.

Letmeseeletmesee. A pearl of blood on his lower lid. Danny? I’m dizzy. My heart’s in my ears. Open your eye. Open it.

A red dot on his white sclera. He blinked. He must have blinked at the exact right time, and the pellet bounced off his lid. Can you believe it?

He never told. He wanted to keep the gun too.

These days, we don’t need guns to feed our family, only to kill people from far away. As such, between humans, they bring only misery, never salvation. Not in my dreams, not in the world. Until then, we live diminished by the distance they afford.

“Once a photograph of the Earth, taken from the outside, is available, a new idea as powerful as any in history will be let loose.” Fred Hoyle

40 years ago. A beautiful 20 min doc describing the “overview effect”, the experience of unity of self and world, that astronauts have on seeing the earth from space. Please watch and share widely. The people are waking.

 

 

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.

i am, and that’s the way it is.

one saturday night, in dadaab, we stood in a puddle around stacked soda crates, a goat sizzling over coals beside us, when the three, buzzed-out speakers in the canteen started to play this song and the same dozen cast of characters that i share my hospital days and compound nights with drifted to the tent, and danced, grinning, mud between their bare toes.

soon, it was only me and one of the departing three for whom the party was held leaning on the red cubes of coca-cola, and we agreed that there was no club in new york city that was better than this one, none where you could dance so sincerely, freed completely from the fear that there might be another, better way to spend your time.

this afternoon, i tried to walk from my outpatient clinic to the ward, and was stopped every three yards by a somali woman who pointed at the baby on her hip before detailing an illness in a language i could’t understand. one of the nurses smiled as he walked by. you’re going to miss being so famous when you leave, he said. i will.

so i nodded my head to the beat of a mother’s wagging finger, and over her shoulder saw the familiar eyes of a woman from the TFC’s (therapeutic feeding center) perilous first bed. i looked into them each morning as she asked me, wordlessly, to do something more, anything. he’s dying, she would say. i know, i know. patience. he’ll make it, i said, only half believing.

now she was moving through the gate’s swinging door, a box with a month’s worth of cups and shawls and mats and plates under her arm. behind, an older daughter carried her happy young brother, newly discharged. his mother and i looked at each other, as we had each day for a month. this time she raised her hand in the air, shook it as she walked past. though i will never be on the field for a goal that 60 000 fans will cheer, there’s no way it could sound any sweeter than the beads did clacking on her wrist.

the credit, of course, was hers and the trip she made back and forth to the jug of ORS so she could pour water in as fast as it poured out, the nurses who took over when she was too tired, the people who gave us money for the tin cup she used. but it is these moments that are so remarkable, that they keep us coming back, are worth all the sleeplessness and latrine running, daydreams of drooping faces, the awkwardness of a home that fits you less well than it did before you left because we get to be witness to the concentrated effect of the human spirit’s brightest part; intention manifested.

i remember once, months and a lifetime ago i watched a lizard track a moth up a wall. as she fluttered from one face to another, the lizard leaped, flew, narrowly missed, and the bug bumped back to the burning light. in that instant, i saw how lizards became birds. not by trying to grow feathers, and not by imagining what it would be like to fly, but by wanting that moth in their mouth so sincerely. the wings come later, but they fit perfectly.

you become what you pay attention to. and what that is, there are no rules, only possibilities. we’re all making it up what a human being is as we go along, moment to moment, and if you’re not deciding, someone is. in that understanding is a scary freedom and the world’s real magic, that as the universe manifests perpetual change, it does it, at least in part, through our imaginations.

intention made manifest. for me, some of it is self evident. msf is the world’s largest medical NGO and despite a teetering financial system around the world where even the most confident economist admits she doesn’t know what’s going on, its budget is the largest in its history, made up almost entirely by contributions of individuals around the world who give a few dollars each towards the idea that reducing suffering, even by a little bit, lightens the weight on us all.

with that money, we mark on maps military movements, to decide if we can get close enough to strike, not with weapons, but with a hospital large enough to accommodate the wounded from both sides, the hundreds of civilians who are drawn screaming into today’s modern version of war. with it, we sit like i did the other day, with a group of new arrivals who walked for kilometres through the desert heat to give up their freedom in dagahaley because it was better here, in this place where camels drop, than where they came from. among them, was a young mother who had delivered just the day before, on the road, a tiny baby, invisible under scarf. it wasn’t until she pulled it aside that i saw him, fragile and new, clinging to her breast. we said to her, we’ll take you to the hospital to rest, and we’ll find room for your husband too, and tomorrow we’ll help you work on tents and food, don’t fear, we’re here, you’re safe. it’s not near as sweet as kissing away the tears of someone you love, but it’s about as close as strangers can get, and if there’s any hope to be had in the world, it is in this direction.

like any optimist would, i deny the aspersion, citing realism. either way, i think we’re slowly winning, and if you’re not convinced, talk to your grandpa who lost two brothers to measles and one in the war, then take a walk down your quiet city street. but as you do, and the thousand dollar computer in your pocket shuffles songs, remember that there are still places where tin cups matter. it starts outside this door, the one with the curtain billowing in the sandy wind, and it reaches to the curb you’re stepping off of.

the work is never perfect, only better. but we try, sincerely, and one day, maybe, wings that fit.