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The dead and dying were strewn everywhere along the dirt road. Patients were identified with bits of tape with a 1, 2 or 3 on their foreheads: 1 meant treat immediately, 2 meant treat within 24 hours, and 3 meant they should be left to die. This was Rwanda at the height of the genocide in 1994.

She was a 1, and James Orbinski, a Canadian doctor working with Médecins Sans Frontières, knelt beside her bloodied body, suturing her wounds as quickly as possible.

Conscious, afraid and trembling, she reached out her hand to touch his arm. “Only then,” he writes in his personal and political book, An Imperfect Offering: Humanitarian Action in the Twenty-first Century, “did I understand what had happened to her.”

She had been raped. Semen and blood covered her thighs. Her ears had been cut off. So had her breasts. Both Achilles tendons had been severed. Her attackers had carefully mutilated her, not to kill her quickly, but just enough to make her die slowly.

He noticed a pattern one of her attackers had carved into her face with a machete. “I turned from her and vomited for the first and only time during the genocide,” he writes. She touched his arm again. “Ummera-sha,” she murmured. “Allez, allez … Ummera-sha,” she repeated in a whisper. “Go, go. Courage, courage, my friend,” she was saying. She knew there were hundreds more who needed care. “It was the clearest voice I have ever heard,” Dr. Orbinski says.

That is just one of the moving recollections Dr. Orbinski makes in his thoughtful and passionate book about the importance of a humanitarian global consciousness. He joined MSF in 1992, and seven years later, accepted the Nobel Peace Prize on its behalf as international president of the global relief agency.

The section in his book about Rwanda, where he worked alongside General Roméo Dallaire, who headed up the UN peacekeeping force, was the most difficult to write. “In a way, the obstruction to writing everything else was the chapter on the genocide,” he said in a recent interview. “The first draft of it took five months. It was extremely difficult. It was the first time I went back and tried to carefully reassemble what actually happened, my experience of it and my role in it, and the experience and role of MSF in it.”

Dr. Orbinski, 48, is wearing a suit, sitting in the offices of his publisher. He graciously accepts questions like a doctor carefully listening to his patient's complaints. But beneath the pressed exterior, he appears restless. The hint of discomfort seems to come from all that he has seen and experienced and tried to reconcile.

“I am not going to tell you that I do not feel despair,” he concedes uneasily at one point, reluctant to talk about his emotional reaction to what he witnessed.

In his book, Dr. Orbinski is far more forthcoming. He recalls that as a child growing up in Montreal, he became aware of the Holocaust and woke up at night in tears. From a young age, he was finely attuned to questions about suffering inflicted by one human being on another. “The question that drives me the most, and fascinates me the most, is the relationship between people,” he says. “That's how I found my way to medicine. As a physician, you have access to what is one of the most intimate spaces of human existence, which is suffering.”

He writes candidly about weeping over scenes he witnessed, including the time he was in a morgue in Rwanda, where he had placed a dead baby the day before. He noticed movement at the head of the infant's wrapped body, and upon closer inspection, saw a rat scurry away.

He describes the post-traumatic stress disorder he suffered upon his return to Canada. Once, when driving along Toronto's Highway 401 to see his parents, he had a flashback to the time he saw children's severed fingers on the ground. “Instantly, my car filled with the sweet smell of freshly killed flesh and blood,” he writes. He veered across the road, bumped the guardrail and came to a stop. For the next three hours, he drove around. Over dinner at his parents' house, his mother began to weep, wishing he had never gone to Rwanda. “You're not the same,” she cried.

In conversation, however, it's as if Dr. Orbinski is in doctor mode, tending to the task at hand – putting out his message about the need for involvement – rather than focusing on himself.

His cure for the PTSD he suffered was therapy but also engagement in political and humanitarian issues. “In contemporary Western culture and, most particularly, in North American culture, there's a deep tendency to medicalize what are, in fact, political and existential questions,” he says. “Which is not to say that there aren't medical dimensions to the traumatic experience. … But the real question is what do you do with what you now know, and for me, the choice was very clear: that I will do everything I can to confront a political system that allows for a genocide to take place.”

His passionate declaration that positive action is his choice is a tacit acknowledgment of its alternative, of which he is also acutely aware. “There's always the other side – [the world is] a terrible place, but it's a beautiful place,” he offers at one point.

His awareness of all that the human heart is capable of is obvious in the book, which is about imperfection in several ways – the world is not wholly good or bad; humanitarian care fails to cheat death as much as it prevents it; and as a human being, he lives with faith that can only partially quell despair. With descriptions of his visits to Brother Benedict, a Montreal-area monk whom he first met when he was a teenager and thought he wanted to join a monastery, and mention of his “growing collection of sacred places” – abandoned lots, a corner in a park, his wild garden – it is clear that his choice against despair has a certain fragility.

It's there in the way he pauses and sometimes sighs a bit when asked about what he witnessed. “When you see death, when you see the limits of life, the limits of politics,” he says, drawing a deep breath before continuing, “the other thing that comes [aside from the need to engage politically] is a sense of humility, a sense of impermanence, a sense of the now. While everything changes, there's now, and what you see, and what you feel, how you listen, how you are – that matters,” he says slowly.

His wife, Rolie Srivastava, and their family of two boys aged four and three and a girl born 10 days ago, have helped create a life that is calm and loving. He formally left MSF in 2004 to become a research scientist and associate professor at St. Michael's Hospital and the University of Toronto.

That same year, he founded Dignitas International, a “hybrid academic NGO” focused on HIV care and prevention, with which he still frequently travels to Africa and other parts of the world. But he doesn't miss the front-line work he once pursued. “I don't miss the heat and the passion of war. I certainly don't feel the need or desire to willfully put myself in a dangerous situation for the sake of feeling something.”

Perhaps that's because he has already pursued his question about suffering at its most extreme, and there's nothing more he can know.

“Yes, I was altered,” he says, when pressed about the personal toll of having experienced what he did. “But who wouldn't want to be?” he demands.

Does that make it easier to live, knowing what we are capable of? “I know what genocide looks like,” he shoots back. “I know what famine looks like. I know what epidemic disease looks like. To retreat to some kind of utopian bubble is actually a form of suicide.”

He leans forward, his face pinched. “This thin veneer of civility that allows for relative peace and prosperity here,” he says, gesturing with one hand, “is kept alive by people who … constantly challenge and reassert the very basic ideas – that you respect people, that even your enemies you will not torture, that you have a duty as a human being to ensure that civilians who are suffering as a consequence of a war that you are engaged in have basic humanitarian rights.” As he finishes that last sentence, Dr. Orbinski collapses back in his chair.

Dr. Orbinski will be speaking on the following dates:

- May 1, Toronto, Church of the Holy Trinity (presented by Pages Books and Magazines), 10 Trinity Square, 416-598-1447.

- May 4, Vancouver, Capilano College Performing Arts Theatre, 2055 Purcell Way, 604-990-7810.

- May 13, Waterloo, Ont., Knox Presbyterian Church (presented by Words Worth Books), 50 Erb St. W., 519- 884-2665.