Orbinski’s new book, An Imperfect Offering: Humanitarian Action in the Twenty-First Century, to be published April 22 by Doubleday Canada, traces the journey of a humanitarian doctor who has served in some of the world’s most dangerous conflict zones. Orbinski, 47, was international president of Médecins Sans Frontières (Doctors Without Borders/MSF) from 1998 to 2001, and he accepted the Nobel Peace Prize on the organization’s behalf in 1999. Over the past quarter-century, he has worked in places such as Somalia during the famine and civil war; in the refugee camps in Jalalabad, Afghanistan; and at the Kosovo Macedonia border during the NATO bombings in 1999. His book explores every facet of his work, from the deeply personal to the broadly political: How does a man persevere – and, furthermore, create meaning and invoke change – after witnessing the most violent, sadistic acts human beings can inflict on one another? What is the role of the humanitarian in the post–Cold War era, in which traditional rules of war have been swapped for anything-goes ethical nihilism? How could MSF confront politics and public apathy during crises so it had the space and resources to heal patients? The notion of imperfection permeates many of Orbinski’s answers. “The book’s title is inspired by the poem and song Anthem, by Leonard Cohen, and there’s a beautiful line where he says, ‘Forget your perfect offering. There is a crack in everything,’” says Orbinski, who earned a master’s degree in international relations from U of T in 1998. “When I read that poem, it struck me that that’s the essence of my experience over the last 20 years as a physician, as a putative humanitarian, as a person who has tried in various ways to influence the political processes that determine who gets what, when. It’s very much an imperfect process with equally imperfect outcomes, but it doesn’t obviate the absolute necessity of trying. You achieve something, and sometimes just enough to go on.”

“The story in the book of the young boy whose leg I amputated is a very good example of that. The boy survived. His mother obviously loves him and he is alive, and had I not amputated his leg he probably would have died within 24 hours of gangrene or sepsis. On the one hand it is absolutely ideal that he’s alive, and on the other hand it’s far from ideal that he is without a leg. But here we are.”

Orbinski was born in England in 1960, and his Irish-born parents immigrated to Canada with their four young children when Orbinski was seven. The family settled in the Montreal neighbourhood of Notre-Dame-de-Grâce, then home to many English-speaking immigrants and working poor. Orbinski recounts in his book how, at the age of nine, he learned “a different knowing of death” – that humans didn’t only die naturally, but at the hands of one another. He saw a television program on the Holocaust, with images of people lying dead at Auschwitz and of a woman with numbers tattooed on her forearm. The next day, Orbinski’s mother took him to the Jewish quarter of the city, as she did before the start of every school year, to buy him new shoes. A very kind old man with beautiful eyes helped him, and called him a good boy. He noticed the man had numbers tattooed on his arm. Orbinski woke up crying that night, after having nightmares of himself, family members and the old man taking off their new shoes for the Nazis.

As Orbinski became older, he knew he wanted to help relieve the suffering of others. He earned a psychology degree from Trent University, and was employed for two years as a youth worker at a juvenile detention centre in Calgary. He then entered McMaster University as a medical student and became immediately enthralled with the study of immunology. Orbinski speaks often about the idea of “living your question.” In his book, he describes his question as, “How am I to be, how are we to be in relation to the suffering of others?” In his gentle, thoughtful tone, he elaborates on this concept. “To enter into what draws you, what calls you, is to live your question…. I have always been fascinated with science, particularly with the methodology of science, and what this means in terms of action – what you can do with what you know. My questions have really come out of these loves and I’ve been drawn to what is classically defined as humanitarian medicine, humanitarian work.”

Orbinski’s humanitarian journey began in earnest at age 27, when he obtained a fellowship to research pediatric HIV/AIDS in Rwanda. For a year, he worked at hospitals and clinics and witnessed extreme poverty, malnutrition and the prevalence of diseases such as polio, which left many paralyzed and would have been easily contained within the Canadian medical system. He became engrossed with moral questions surrounding the unequal distribution of resources, and the economic and political forces that caused such severe inequities. After returning to McMaster, Orbinski heard that student Richard Heinzl (BSc 1986 UC), was creating a Canadian chapter of Médecins Sans Frontières – an international group that provides medical assistance to victims of war and other catastrophes. The organization practiced strict impartiality while assisting victims, providing aid based solely on need and irrespective of politics, race or religion. However, MSF differed from groups such as the Red Cross in that members spoke out against human rights violations to create public awareness of atrocities. Orbinski became a founding member of MSF Canada, and one of his first missions was to Baidoa, Somalia, in October 1992. Hundreds of thousands had already died in the famine induced by a civil war that had been raging for two years. More than half of the country’s eight million people were on the verge of starvation. In the midst of rampant violence, Orbinski and other MSF team members provided medical care at clinics and feeding centres in Baidoa and surrounding villages. They often treated up to 2,000 patients a day, while hundreds more waited outside clinics suffering from starvation and the diseases that accompany it.

One day in June, when violence was at an apex, Red Cross and MSF staff treated hundreds of people in the Red Cross hospital, on the grounds and lying along the road. Heavy shelling and mortar fire hailed from everywhere. Snipers, some with rocket-propelled grenades, were pervasive. The blood of the dead and wounded ran in the gutters. Orbinski and his team performed triage work, taping numbers to the patients’ foreheads. A “1” meant treat right away; a “2” meant treat within 24 hours. Those who had “3” were “irretrievable.” They were moved to a small hill, made as comfortable as possible with blankets, water and available morphine. This was where they died.

In his book, Orbinski writes that he “felt beaten by the waves of suffering, of killing, of screams, of silent stares, of terror, and waves of not just political indifference but malfeasance.” He had acted and spoken, while an entire world stood by without helping. He remained while the violence eddied more constrictively around the hospitals – until he was one of the last doctors left in Kigali. He made a choice. His choice was to stay and save what lives he could, to relieve what suffering he could – it was that simple, and that hard. He did not leave until the genocide ended.

Orbinski has returned to Rwanda numerous times since the genocide; his latest journey, in 1997, was captured in Triage: Dr. James Orbinski’s Humanitarian Dilemma. The documentary, directed by Patrick Reed, screened at the Sundance Film Festival in Utah this January. How did Orbinski cope during his time in Rwanda? How did he carry on? Orbinski speaks about his experiences collectively, about the role of the humanitarian. “There are moments in a particular story [in An Imperfect Offering] where I knew that my fear overwhelmed everything else, and there are other moments where the implications of not acting or speaking overwhelmed my fear.” Later, he adds, “What I’ve experienced is that I can’t know the future. I can’t know if anything that I do will change what happens tomorrow. I can’t know with certainty, but what I do know is if I do nothing, nothing will change.”

But it was the Rwandan Genocide, during which Orbinski served as MSF’s head of mission, that he has called both “my undoing” and “the most transformative moment in my life.” During the 100-day period from April to July 1994, one million men, women and children – including 85 per cent of all Tutsis in Rwanda – were murdered, and another half-million people (including moderate Hutus) were injured, by Hutu extremists. Orbinski entered Rwanda in mid-May, at a time when almost everyone else – from UN agencies, to aid organizations, to the U.S. Marines – had fled. (By early April, only MSF, the Red Cross, the UN peacekeeping force headed by Roméo Dallaire, and two UN humanitarian members remained in Kigali.) Orbinski split his time among the King Faycal Hospital, the UN compound, the Red Cross Hospital and a stadium filled with 12,000 people seeking refuge. When he arrived at the Faycal Hospital, 6,000 people occupied every recess of the building, from the stairwells to the closets. Orbinski and other MSF members worked 16- to 18-hour days while outside, killing squads continued to slaughter men, women and children. The MSF team treated waves of victims with machete wounds, gunshot wounds and shrapnel injuries. They cared for people who had chest injuries from being buried alive; women and girls who had been raped; and those maimed by grenades and land mines. They established an orphanage in Faycal Hospital for children whose parents had been killed. And still, more and more victims arrived.

In human experience, language can enlighten but it can also entrap. One word can be so gravid with meaning that it could ignite the outrage of citizens, the deployment of troops, the legal obligation of action. Its absence, on the other hand, could promote the opposite reaction: the absence of deed. In 1994, as hundreds of thousands were slaughtered in Rwanda, the UN Security Council refused to invoke the word “genocide” – pressured largely by the Clinton administration, which did not want to use the word because it would legally obligate them to send troops to the country. (A year earlier, U.S. troops had intervened in Somalia’s civil war. Eighteen American soldiers were killed, and the images of two dead soldiers being dragged through the streets of Mogadishu were televised worldwide; Clinton did not want to become involved in another international peacekeeping operation.) Orbinski and MSF, however, called for the use of the word “genocide” by the United Nations; they called for a UN-mandated military intervention to stop the killing; and they spoke out to the media to illuminate the horror of the genocide. “Humanitarianism, at its root, is about the direct relief of suffering in terms of action, but it’s predicated on a basic respect for the dignity of the human being,” says Orbinski. “In practice war is not always waged according to the rules. So when the rules of war are broken – war crimes against humanity, and in the most extreme circumstance, genocide – it’s an obligation of the humanitarian to call into question the actions of those who are breaking those rules, and also to call to accountability the political decisions that are made. In Kigali, Rwanda, during the genocide, it was very clear that there was no humanitarian space. Genocide is the complete obverse of humanitarianism. There is, by definition, no respect for the dignity of others or of the intended victim. There’s no limit on the use of force. The intent is actually to eliminate the very existence of the other, and so the possibility of humanitarianism simply does not exist in that circumstance.”

“MSF insisted that there be a right political response to the genocide, and the international criminal court was created in response to that debate…. However apparently dispiriting and apparently futile the world may seem, it’s anything but if we assume our responsibilities as citizens and as human beings, if we speak. [Political philosopher] Hannah Arendt said that the first political act is to speak and I think that she was absolutely right.”

In 2004, Orbinski and James Fraser, another doctor with MSF, travelled to the Zomba Central Hospital in Malawi, Africa. Ninety per cent of the patients were HIV-positive, and hundreds of critically ill men, women and children crowded the building: three to four patients were packed to a bed; others lay suffering on the floor and under the beds; and more still were gathered under trees on the hospital grounds. The medical staff consisted of one nurse. The hospital reflected the reality of the health-care system and the AIDS epidemic across much of Malawi and the developing world. (In Malawi, there are 12 million people – roughly the population of Ontario – but only 100 doctors. Fourteen per cent of the population is HIV-positive. In the Zomba region, 20 per cent are HIV-positive.) “It was just overwhelming. Overwhelming for me, but also, even more obviously, for that nurse,” says Orbinski. “And for both James Fraser and myself, it was just clear we had to do something about this.”

What Orbinski and Fraser did was leave MSF to create Dignitas International, an organization that develops community-based care and treatment programs for people who are HIV-positive and have AIDS. While the group does train doctors, it focuses mainly on training nurses, lab technicians and other health-care workers. “One of the big issues in Malawi and much of the developing world is the level of education in the general population and illiteracy, and so there are not a large number of people who are highly educated. But just because you’re not educated doesn’t mean you’re not smart,” says Orbinski, who doesn’t get paid for his role as co-founder and chair of Dignitas. “If you can develop a set of tools that are scientifically valid and allow for a person with a Grade 8 or Grade 9 education to actually deliver treatment, to do proper assessment and management, then you can empower those people and communities appropriately to actually control and contain an epidemic.”

Dignitas now has about 10,000 HIV-positive people under its medical care, almost 5,000 of whom are receiving AIDS treatment. The organization works with Malawi’s Ministry of Health officials and community groups and, in a few years, has trained hundreds of health-care workers, delivered AIDS education to more than 100,000 people in the Zomba district, built a lab and other medical facilities and provided social support to AIDS orphans and women’s groups. The organization is now establishing a network of research institutions – with the University of Toronto, University of Malawi, the BC Centre for Excellence in HIV/AIDS and others – so they can share their knowledge and let others take up the model. Orbinski focuses, through Dignitas, on community- based care and HIV/AIDS in his role as a research scientist at St. Michael’s Hospital. As a professor of political science at the University of Toronto, Orbinski is also working with U of T professors at the Department of Public Health Sciences to create a collaborative PhD program in global health. The program is slated to begin in September, and he will be teaching the core course.

Orbinski also has more personal productions underway. He and his wife, Rolie Srivastava – an environmental-sciences researcher whom he met after returning from a journey to Rwanda in 1996 – are expecting their third child in mid- April. The baby will join brothers Rohin, age four, and Taidgh, age three. And this afternoon, a very excited Orbinski is taking a very excited Rohin to his first skating lesson. Orbinski and Srivastava made up a cheer for him last night, and sang it to him again this morning. Orbinski breaks into song. “Rohin Orbinski, faster than a Jet Ski/If he was any taller, you’d think he was Wayne Gretzky.”

Did Orbinski always envision himself doing humanitarian work? He answers thoughtfully. “The question is this idea of fate, and of a kind of a determined future…. I don’t have that experience. I think if anything, one of the core ideas that I am trying to express through this writing and also through the film, is that it’s a choice. Every moment in your life is a choice, and we have a choice as to how we will see the world and how we will see ourselves in it, and therefore what we will do,” he says. He later adds, “What I do know is that I have tried to live my question, to really understand my question and struggled in the answers that emerged – however imperfect they may be.”

Stacey Gibson is the managing editor of U of T Magazine.

Brady might have spent the rest of his life as a motor quadriplegic – paralyzed from the neck down, with minimal sensation in his legs – if not for the surgery that he underwent at Toronto Western Hospital three days after his injury. The operation relieved pressure on his spinal cord and fused five upper vertebrae together with a steel bar. Within two weeks Brady was able to stand and take a few steps; after three weeks he was walking quite well. Today, a year later, he says with some amazement, “I’m fully mobile.” Although Brady still suffers from a stiff neck and pain in his upper arms, in February he returned to his physically demanding job as an industrial sheet metal worker.

Paralyzed patients walking away from their injuries? It sounds like the stuff of science fiction. But U of T researchers say new surgical techniques, drugs, gene therapies and rehabilitation devices are helping to make significant improvements in the lives of people with spinal cord injuries. “There is real hope, and there has been real progress,” says neurosurgeon Michael Fehlings, a U of T professor in the department of surgery and the one who operated on Brady. Fehlings is also the director of the spinal program at Toronto Western’s Krembil Neuroscience Centre, the largest neuroscience centre in Canada and a world leader in spinal cord research. As he leads the way through his lab, where graduate and undergraduate students are busily examining tissue sections of a spinal cord under a microscope, characterizing types of neural stem cells, and performing delicate spinal surgery on a rodent behind closed curtains, he says, “There’s work going on all over the world, but much of the seminal work has occurred in Canada, and U of T is right in the thick of things.”

Bruce Brady’s case is an example of only one exciting strategy being used to repair the spinal cord. Brady is one of 250 people enrolled in a clinical study called STASCIS, which stands for Surgical Treatment for Acute Spinal Cord Injury Study. Fehlings, who is spearheading the multicentre study, says that in the past, patients like Brady wouldn’t have received surgery at all – let alone surgery so soon after their injury – because their necks weren’t broken but “merely” compressed. In one-third of spinal cord injuries, especially in aging but active baby boomers such as Brady, the spinal cord undergoes a combination of contusion and compression. The cord (actually a long thin bundle of nerves enclosed by the vertebrae) is jolted against bone spurs, which develop as we age, and then jammed into the tight spinal canal.

While compression sounds less serious than a fracture, the results can be just as devastating because after the trauma the nerve cells inside the spinal cord start to die, causing loss of movement, sensation, bladder and bowel control, and sexual function. “Without decompression surgery, it’s doubtful that Bruce would have improved from a complete motor quadriplegic after injury to virtually normal,” says Fehlings. The STASCIS data are just starting to emerge, but Fehlings hopes they will help determine the optimal time for surgery; so far it’s looking as though the earlier, the better. The next step: establishing guidelines about how and when to use the surgery, and spreading knowledge of the technique to certain designated hospitals across Canada. As Fehlings puts it, we’re entering a golden era of spinal cord research, reflected at U of T in a special collaboration among the fields of biology, chemistry and engineering. And Canadian research is attracting worldwide attention.

“Twenty years ago, a cure for spinal cord injury seemed impossible,” says Rick Hansen, who at that time had just finished famously wheeling through 34 countries on his Man in Motion World Tour to raise awareness and funds. “Today, it has been proven that the spinal cord can regrow, and we’re seeing an increasing number of people walking away with partial or full recovery.” He adds, “I feel proud to see Canadians leading the way in the global search for a cure.”

The whole field of spinal cord repair has changed dramatically since Hansen’s world tour in 1985, and especially since “Superman” Christopher Reeve’s equestrian accident in 1995. For millennia, spinal cord injury for most people had been a death sentence; unable to control their bladder or bowels, patients died of bladder infections. When antibiotics became available in the 1940s, mortality rates dropped. But even as recently as the 1980s, 40 per cent of patients died within a year of injury to the upper spinal cord. Today’s rate: only about five per cent.

A modern turning point occurred when Fehlings – who has an MD and a PhD – was a graduate student working under Dr. Charles Tator, then chairman of Uof T’s division of neurosurgery (and currently a Uof T professor of surgery and a recipient of the Order of Canada). Together Tator and Fehlings played a major role in a discovery that shook up the global scientific community when they published their work in 1991. The hypothesis – controversial at the time but now widely accepted as fact – was that spinal cord injury is a twostep process. First there’s the initial mechanical trauma. But following that, there’s a secondary injury: the spinal cord undergoes a kind of stroke. The blood vessels, disrupted by the initial injury, interrupt blood flow to the nerve cells, which die, greatly amplifying the original damage. These secondary injuries occur anywhere from minutes to months afterward. Fehlings says, “So while we couldn’t undo the initial injury, we thought, You know what? We might be able to intervene to prevent the secondary injury from happening.” It’s now a standard of care for patients to receive medicines immediately following injury to bump up their blood pressure and improve blood flow to prevent secondary damage.

But Fehlings believes there’s much more we can do to protect those vulnerable nerve cells. In work that won the Gold Medal Award in Surgery from the Royal College of Physicians and Surgeons of Canada, his own lab determined that spinal cord injury causes a dangerous shift in the critical balance of the natural salts in the injured cells. Within hours of the injury, sodium enters the cells, followed by water, which causes swelling. This then attracts calcium into the cells, triggering damage far beyond the initial injury. Fehlings is looking for a way to prevent this from happening

One possibility may be a drug called riluzole. Originally developed as an anti-epileptic, it also seems to slow the rate of nerve cell degeneration in people with amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease. Could riluzole also have neuroprotective effects in people with spinal cord injury? Fehlings is attempting to find out, and later this year will launch a clinical trial with riluzole. Much of the funding for the study will come from the Christopher and Dana Reeve Foundation, which has designated nine centres of excellence in North America to take promising therapies and move them into clinical use. Of the nine centres chosen, the Krembil Neuroscience Centre is the only one in Canada.

If riluzole works, it could have important implications all over the world – including among soldiers in Iraq and Afghanistan. “With their body armour, soldiers aren’t dying of torso injuries like they did in Vietnam,” Fehlings explains. “But with these crazy bombs, the vehicle implodes and the soldier’s spine gets crushed. We received a $3-million grant from the U.S. Department of Defense to do clinical trials on spinal cord injury, and they like riluzole because it can be given as a pill by a medic in the field.” Riluzole, now off patent and very cheap, would be particularly welcome in developing countries, where spinal cord injuries are prevalent due to the lack of safe roads, safe vehicles, seatbelts and workplace regulations.

But protecting nerve cells from degeneration is only half the story. The other half involves regenerating nerves that have already been damaged. It’s been known for a long time that if you sever a nerve in your arm or leg, it will eventually regenerate on its own. That doesn’t happen in the spinal cord. Why not? In another important Canadian discovery, a group of Montreal researchers found that the culprit was myelin, the insulating layer around the nerve fibres. The myelin in the spinal cord, which transmits signals from the brain, contains inhibitors that block regeneration.

There are intensive efforts now to find the best way to stop that process and encourage regeneration. One option is Cethrin, a protein drug that can be applied directly onto the spinal cord during surgery. Developed by Montreal neuroscientist Lisa McKerracher, Cethrin recently underwent the first phase of clinical trials in eight centres, one of which is the Krembil. Of the 37 patients, all of whom had no muscle function or feeling below the site of their injury, about one-third showed some recovery, and 15 per cent showed major recovery, such as regaining hand function or leg movement.

One study participant is a 64-year-old Toronto shopkeeper who broke his neck when he fell face first against the door of his shop. Because he immediately went into cardiac arrest, surgeons couldn’t operate on him until he stabilized, five days later. Fehlings met him in the intensive care unit. “He was a quadriplegic, with no movement in his shoulders or hands and no control of his bowel or bladder,” Fehlings says. Following the surgery and treatment with Cethrin, the man recovered partial use of his hands and can now feed himself. He also regained control of his bowel and bladder, and with assistance he can stand and take a few steps. “I was shocked,” says Fehlings. “Shocked! I had never seen that in my career.” While spontaneous recovery occurs in seven per cent of cases of spinal cord injury, he says, “The chances that somebody with a complete spinal cord injury at five days would spontaneously recover like that are close to zero.” The U.S. Food and Drug Administration has given the green light to move forward with a large randomized Cethrin trial later this year.

Another exciting avenue of research involves replacing damaged nerve cells with neural stem cells. Collaborating with U of T stem cell researchers Cindi Morshead and Derek van der Kooy, Fehlings’ lab performed tests on rodents whose spines were crushed. The neural stem cells served to regenerate the original damaged cells, and some of the animals recovered the ability to walk. This strategy is close to clinical trials, and may one day also have major implications for people with multiple sclerosis and for children born without myelin.

While developing the right drug or combination of molecules is crucial, it’s equally important to have a way of getting the medicine to where it needs to go. Many of the drugs can’t be taken orally or intravenously because of severe side-effects, and if they’re injected into the spinal cord they’ll simply be washed away along the river of spinal fluid. How to get the drugs to stay put and do their job? Molly Shoichet, Canada Research Chair in Tissue Engineering and a U of T professor in the Department of Chemical Engineering and Applied Chemistry, leads a team that has developed a unique water-based gel made of naturally derived hyaluronan and methylcellulose, both carbohydrates.

Shoichet, happy to demonstrate the remarkable properties of this gel, grabs a syringe from her lab in U of T’s Terrence Donnelly Centre for Cellular and Biomolecular Research. “Just push lightly,” says Shoichet as she hands over the syringe with its very fine 30-gauge needle. “See the gel coming out? When you apply pressure it thins and flows through the needle, but when it comes out it gels immediately.” In animal testing, not only did the gel succeed in delivering the drug on top of the spinal cord in a minimally invasive procedure, but it sealed up the hole made by the needle and minimized inflammation after the injury. “It’s very cool and there’s nobody else who has done anything quite like this, so we’re very excited,” Shoichet says. The gel keeps the drug in place for a few days, but the goal now is to extend that time to 30 days of drug therapy with a single injection.

Shoichet’s team, in collaboration with Charles Tator’s lab, has also developed a tiny tube designed to bridge the gap in a severed spinal cord and encourage nerves to regenerate. Only five millimetres long and made of a degradable sugarbased polymer, the tube looks like a soft, transparent, miniature drinking straw with the consistency of Jell-O. Incorporated into the tube are stem cells and microbeads that can be filled with proteins that stimulate cell growth. When the tube is inserted into the spinal cords of animal models, it acts as a temporary scaffolding to which cells can adhere. “We get tissue regeneration,” Shoichet says, although that hasn’t yet translated to a significant improvement in the animals’ mobility. “Stem cells have a tremendous amount of potential, and we’re still learning how to harness that.” Another bioengineering strategy to promote nerve cell regeneration involves gene therapy. There’s particular interest in a gene called VEGF, or vascular endothelial growth factor. It’s an important gene that makes blood vessels. In animal studies, rodents with a spinal cord injury who received a gene therapy technique to cause cells to express VEGF showed dramatically improved recovery. More work is needed before this therapy can progress to human trials.

Much of the focus of the clinical trials is on acute injury – the one that’s just happened. So what about the person living with a chronic spinal cord injury? Not only is some of the U of T research targeting chronic patients, but there are promising therapies already under study. It’s been known for 20 years that the main control mechanism for walking is not in the brain but in the spinal cord; the brain merely finetunes it. Therefore, if a person with a spinal cord injury is suspended over a treadmill while physiotherapists manually move his legs rigorously and persistently, his central nervous system can be retrained to contract the muscles in the right order, enabling him to walk. “It really works,” says electrical engineer Milos Popovic, associate professor in U of T’s Institute of Biomaterials and Biomedical Engineering. “But the problem is it’s very time-consuming and labour-intensive. You need three physiotherapists to do this.”

Popovic, who used to design airplane systems, has devised a better way to stimulate the muscles. He invented a portable, programmable, wallet-sized device that delivers electrical stimulation through electrodes, forcing the muscles to contract. The device has been tested on more than four dozen people, some of them who had been living with spinal cord injuries for years. They underwent hour-long sessions either three times a week over 12 to 18 weeks for locomotion, or daily over eight weeks for hand grasping, then were tested on how well they could carry out the movements on their own, without the device. “We got dramatic improvements,” Popovic says. All improved their locomotion, with a resulting reduction in the need for assistive devices. One man, barely able to stand since his spinal cord injury 20 years ago, can now walk. Another went from a wheelchair to two canes. A third, who could walk only slowly, doubled his speed. Popovic, who is also the Toronto Rehabilitation Chair in Spinal Cord Injury Research, is now in the middle of larger-scale trials.

The reality is that some of these surgical, drug and rehab methods will prove to work better than others, and it takes time to figure out which ones are the best and the safest. Meanwhile, some Canadians, impatient for a cure, may be tempted to travel to China, Brazil or Portugal to undergo procedures such as cell transplants that are available there for a price. But researchers here warn that these therapies are unproven and unregulated, and there are risks of serious infection such as meningitis. Worse, the surgery could cause scar tissue that would prevent patients from taking advantage of a better procedure in future. “I can totally understand why a family would want to try this, but the concern is they may burn their bridges,” says Fehlings. “In the past, people would have nothing to lose, but it’s a different story now. The potential for evidence-based therapies that really work is looking very feasible.”

So feasible, in fact, that Fehlings believes we’ll see some important results in the next three to five years. “It’s not just that we’re doing some nice science here,” he stresses. “This is really going to have an impact on people’s health.”

Marcia Kaye (marciakaye.com) of Aurora, Ontario, is a magazine journalist and best-selling author specializing in health issues.

The numbers already tell the tale. While Canada committed to reduce greenhouse gas emissions to six per cent below 1990 levels by 2012, the reality is that we’re more than 30 per cent above that benchmark. And thanks to the oil sands projects in northern Alberta, our emissions continue to rise. During last November’s climate change summit in Bali, the European Union signalled it is looking for a successor to Kyoto that would reduce greenhouse gas emissions by as much as 40 per cent (from 1990 levels) by 2020. For Canada, that would mean cutting our current emissions by more than half.

Canada’s dismal record illustrates the failure of voluntary programs and clean energy subsidies. Under both the Liberals and now the Conservatives, Ottawa has sought to reduce emissions using consumer incentives (for fuel efficient cars and home improvements), research grants, and subsidies for transit and renewable energy projects, such as wind farms. Evidently, this strategy has failed to make a dent. “The problem with the current policies is that they’re all out in the future,” says University of Toronto economics professor Don Dewees. “That’s a mistake because we wind up doing nothing.”

Pointing to Canada’s backsliding, climate change experts increasingly stress the need for a more assertive approach. Some politicians are taking heed. Earlier this year, British Columbia became the first jurisdiction in North America to impose a genuine carbon tax. Until recently, such moves seemed to lack grassroots support. But Dewees has been taken aback by how quickly public opinion is shifting. A poll conducted in February found that three out of four British Columbians support a carbon tax. “A year ago, I would have said, ‘Let’s not talk about a carbon tax because it’s politically hopeless.’ But that’s changing,” says Dewees.

As Canada heads toward the next round of climate talks, slated for December in Poland, we asked several U of T experts to propose an effective climate change strategy that will get us on track to meet our Kyoto commitments – without hobbling the economy.

Establish a national carbon tax
According to Dewees, Canada must move quickly to enact a national $15/tonne carbon tax rather than continue to put off effective change. “A good plan will impose costs everyone will feel within a year,” he says.

The premise behind the carbon tax comes directly out of Economics 101. The earth’s atmosphere has a limited capacity to absorb carbon dioxide (and the five other major greenhouse gases), so this capacity must be treated as a resource with a tangible economic value. “Putting a price on the atmosphere is critical,” says Mark Jaccard, an economist at Simon Fraser University and co-author, with Globe and Mail columnist Jeffrey Simpson, of Hot Air. “The abatement of greenhouse gas emissions will not occur without it.”

But what is the right price? B.C.’s new $10/tonne levy on carbon emissions will add less than three cents to the cost of a litre of gasoline and heating oil, although the tax will rise to $30/tonne by 2012 – a ramp-up Dewees describes as “aggressive but possible.” Some proponents argue that Ottawa should set a national carbon tax at $30/tonne of emissions, and raise the rate at regular intervals to $100 by 2030. Dewees believes a target of $50 by 2020 is more realistic.

Then there is the question of what the government should do with the extra revenue. Some environmental groups, such as the Pembina Institute, argue that governments should use the carbon tax windfall to fund transit and renewable energy projects. But Dewees disagrees, arguing that the money should be returned to taxpayers either in the form of a rebate or lower income, corporate or sales taxes. He points to the quid pro quo at the heart of B.C.’s new carbon tax; alongside the new levy, the government said it would give every citizen a $100 rebate. In other words, the government won’t suck additional tax dollars out of the economy. “Without that linkage,” says Dewees, “I think this will be a really tough sell [for voters].”

Another critical element of a national carbon tax is its simplicity. While B.C. imposed the tax at the consumer level (you pay when you buy gas, for example), Dewees argues in favour of applying the tax at the point of production: the refinery or the coal mine. “Because there are many small sources of carbon dioxide (gas furnaces, motor vehicles), imposing the tax at the point of emission is much more costly than imposing it upstream at the level of wholesaler or even producer or importer.” Ultimately, consumers will feel the impact as producers pass along the extra cost of paying the tax.

The final piece of an effective national carbon tax plan involves public information. Ottawa must inform consumers and businesses about future increases in the levy well in advance, says Dewees. If the long-term schedule of carbon tax hikes is well known and then adhered to, consumers and companies can make long-term decisions that anticipate the rising cost of fossil fuels. In other words, if a car buyer or a homeowner shopping for a new furnace knows that, three years from now, fuel prices will rise due to an increase in the carbon tax, they will be better positioned to calculate the long-term financial benefit of purchasing a more energy-efficient product.

Likewise, when energy companies invest in new equipment, their planning horizon is often 15 to 20 years. “We’re caught in the dilemma of industry wanting some certainty about the future,” says Dewees. If firms understand how the regulated price of carbon will change over the long run, they will be able to plan their capital expenditures accordingly.

Beware of “cap-and-trad” loopholes
Under a “cap-and-trade” system, large emitters of greenhouse gases are granted emissions permits, up to a limit. If they can’t meet their target, they have to buy permits from companies that have reduced their emissions below the limit. These permits trade on an exchange. Governments can push industries to improve their overall performance by lowering the limits over time.

In 2005, the European Union established an emissions trading scheme as part of its Kyoto commitment. In Canada, Alberta and the federal government are now developing emissions trading policies for large industrial polluters. Critics predict that these two Canadian trading ventures will fail to make a meaningful dent in emissions, however, because they aim to cut emissions intensity – the proportion of greenhouse gases emitted per unit of production – rather than achieve an absolute reduction, as required by Kyoto.

While he favours the predictability and simplicity of an across-the-board carbon tax, Dewees says the Harper government could press ahead with a “hybrid” climate change plan – one that imposes a carbon tax on small emitters (vehicles, homes, small businesses) and creates an emissions trading system for large industrial companies (cement plants, oil and gas refineries, mines). But economists such as Dewees and Jaccard and many environmentalists warn that cap-and-trade schemes are both administratively complex and vulnerable to compromises that reduce their impact. “A cap-and-trade system involves the very difficult business of deciding who gets what [emission] allowances,” says Dewees. “There’s a lot of lobbying because the government is giving away the right to pollute.”

Cap-and-trade also works better in industries where the emissions-control technology – scrubbers to remove nitrous oxides from smokestacks, for example – is well developed, which is not the case with greenhouse gases. Where there’s a well-established technology, a company can plan to invest in emissions-reducing equipment and thus reduce its need to purchase permits. With greenhouse gases, however, technological solutions, such as pumping carbon dioxide underground and into spent gas wells, remain experimental at best. “Without the control technology,” says Dewees, “the price of the emission allowances will skyrocket.”

Create Sustainable Trade Policies
In a country dependent on trade, a national climate-change policy should be designed to make sure that imports are priced to reflect the true cost of greenhouse gas emissions while our exports aren’t rendered uncompetitive by domestic carbon taxes.

On the export side, Dewees says that if the federal government adopts a carbon tax, it must also provide a credit to the exporter that’s equal to the value of the carbon tax on goods that leave the country. He cites the example of cement, a commodity that creates heavy greenhouse gas emissions while it is being manufactured. Under a carbon tax system, cement produced in Canada might not be able to compete with cement produced in a country without a carbon tax. An export credit solves the problem: the domestic production of a Canadian cement plant will continue to be subject to a carbon tax, but the shipments leaving the country will not.

The question of imports is trickier: if Canada is to adopt a tough-minded climate change plan that will deliver real results, part of the equation must involve looking at the carbon footprint of imports. After all, our contribution to reducing global climate change will be meaningless if we continue to bring in goods produced in countries that ignore their Kyoto obligations.

Faculty of law professor Andrew Green points to a measure that has gained increasing attention in the past year: socalled “border tax adjustments.” The U.K. is studying such a tariff and France has said it supports this kind of duty on imports. The idea is that products imported from countries that are not Kyoto signatories or fail to comply with their Kyoto obligations will be slapped with a tariff that brings their prices up to the levels of goods produced in countries with carbon taxes. The French have threatened to use the border tax adjustment against American imports. Green says Canada is also “in a difficult spot” because of our dismal performance on reducing greenhouse gases. “France is saying that they’ll put taxes at the border against U.S. [goods] because the U.S. is not part of Kyoto,” he says. “We’re [also] vulnerable.”

As Canada and the rest of the world heads into the next climate change summit, Green argues that Ottawa “should try to get trade measures into the next agreement.” The adjustments, he says, must be tough enough to encourage importers to lower their own carbon footprint, but not so high as to become trade barriers. By way of precedent, he cites the Montreal protocol on ozone-depleting substances, which included bans on the trade of goods that use aerosols and other chemicals that destroy the ozone layer. “There must be some sort of sanctioning mechanism in the next [climate change deal].”

Use road pricing to reduce driving
Almost half of Canada’s population is concentrated in six large urban regions, all of which rely increasingly on federal funds for the construction of major transit and transportation projects. If Ottawa wants to meet its climate change goals, it will have to use its clout to persuade the residents of big cities to drive less.

Fossil fuels burned for transportation accounted for 200 megatonnes of greenhouse gas emissions in 2005, or just over a quarter of Canada’s total. Last year, the Harper government announced it would press the auto industry to invest in more energy-efficient vehicles as a means of reducing transportation-related emissions.

Yet this problem isn’t just about the tailpipe and the engine. Most economists believe that when drivers don’t have to pay to use roads and highways, they overuse them, thus increasing emissions. “When I’m driving on a crowded highway, I’m slowing everyone else down but I’m not paying for it,” says Matthew Turner, a U of T professor of economics whose work focuses on urban sprawl and land use. “There’s a case to be made that people drive too much because access to roads doesn’t cost them anything.”

He says road pricing – in the form of highway tolls, congestion fees for driving downtown and higher parking rates – achieves multiple goals: it reduces the sort of congestion that undermines productivity in sprawling urban areas and cuts transportation-related emissions. Turner also believes that road pricing is more effective in altering driver behaviour than carbon taxes, which add only a few cents to the price of a litre of gas. Because both gas guzzlers and hybrid cars will have to pay tolls or congestion charges, such measures will encourage more people to walk, ride bicycles or use transit.

While tolls have existed on U.S. interstates and many European highways for decades, they face considerable political resistance in Canada. But, as with the carbon tax, government tentativeness may be waning. London and Stockholm have congestion charges, while both New York and Greater Toronto are studying them. John Miron, chair of the department of social sciences at U of T Scarborough, points out that the world’s most effective road pricing system can be found in Singapore, which has used a combination of very high vehicle registration fees (over US$100,000) and tolls to limit driving and encourage transit use. While he admits that Singapore’s autocratic form of government and its island status make it a poor model for Canadian cities, the lesson is that moderate road pricing may fail to achieve real change.

As with the carbon tax, the advent of road pricing also raises the question of how the revenues will be used. In London, the congestion charge is earmarked for public transit and bicycle lanes. But Dewees argues against dedicating government revenues to a particular form of spending, such as transit improvements. Miron adds that cities with road pricing must recognize that tolls and congestion charges tend to disadvantage lower-income residents, so some of the revenues should be directed back to them.

Economists such as Turner also note that governments will get the most leverage from their road pricing revenues by investing in cheaper modes of transit, such as buses rather than subways or even light rail. With Canada’s big-city mayors calling on the federal government to establish a national transit strategy, Turner’s research shows that buses represent the most cost-effective investment in terms of providing transportation alternatives to growing urban regions.

The bottom line
No one wants to pay more taxes, but it’s becoming increasingly difficult to ignore the fact that reversing climate change will involve major changes in our fiscal arrangements. Much of the opposition to the carbon tax emanates from fossil-fuel companies, which will experience declining demand for their products if governments impose such levies. Yet Dewees points out that energy firms will migrate into more sustainable business lines, such as wind and solar, or even nuclear power and clean coal, both of which become more financially viable with an assertive national carbon reduction plan.

What’s more, naysayers and lobbyists must contend with the fact that such policies haven’t caused economic havoc elsewhere. Congestion charges in London and Singapore didn’t produce an exodus of commercial activity. As for a national carbon tax, the experience of many European jurisdictions suggests that economic growth and tough climate change policies do co-exist.

Jaccard points to the case of Norway, which introduced a carbon tax in 1991, at $30/tonne. For Canadian policymakers, there are strong comparisons to Norway, which has experienced a boom in offshore oil drilling. The Scandinavian nation has seen a 40 per cent increase in economic growth per capita since the early 1990s, even though the lion’s share of its multibillion-dollar oil and gas revenues end up in a trust fund. Norway’s per-capita emissions have remained flat since 1991, while Canada’s have risen six per cent. Norway has a carbon tax. We don’t. Moral: Growth in the economy isn’t necessarily coupled to growth in emissions. As Jaccard notes, “Evidence suggests that a $100/tonne carbon tax will stimulate substantial reduction in greenhouse gases without devastating the economy.”

John Lorinc (BSc 1987) is a Toronto journalist. His most recent book is The New City (Penguin Canada).

Berry, a Catholic priest from North Carolina, observes that Gore’s ability to communicate the threat of global warming uses the language of morality. Scharper says this offers a clue to policy-makers seeking to break the apparent impasse over a new climate-change deal between the developed North and the developing South.

In his view, and those of a growing number of the world’s religious leaders, the debate must be broadened well beyond the realm of science and policy.To find commonalities and the possibility of consensus, Scharper says, the societies of the North and the South need to find a way to exchange ideas about mutual values, ethical frameworks and cosmology.“When you speak to people at that level, it is for many a moment of galvanization.”

Scharper points out that, increasingly, global religious and spiritual movements have sought to influence the negotiations at important summits such as the Bali conference last November. When the United Nations Development Program began formulating a climate change plan, “they realized they had to enlist the support of the world’s religions if they hoped to change the habits of the heart. It’s not just about policy, but also traditions and values.” And justice: Scharper believes that a globally acceptable climate change agreement must go well beyond the consumption-oriented North imposing environmental constraints on the South. “It’s also a question of just economic relationships.”

As incredible as this research is, even basic medical care remains woefully out of reach for many people in the developing world. Malawi, in southeastern Africa, for example, has only 100 doctors to serve a population the size of Ontario’s. James Orbinski, the co-founder of Doctors without Borders Canada, travelled to Malawi in 2004 and treated patients at the Zomba Central Hospital, where 90 per cent of the sick were HIV-positive. He also worked in Rwanda during the 1994 genocide. As managing editor Stacey Gibson writes in “A Doctor in Kigali” (p. 18), Orbinski’s experiences in Africa transformed him, but also inspired him – to establish Dignitas International, a humanitarian group that trains mostly nurses, lab technicians and other health-care workers in developing countries. Orbinski’s innovative idea provides people who have some high school education with the skills they need to deliver relatively straightforward but essential medical treatment. Just a few years old, Dignitas is already having a big impact in Malawi. Reading about Orbinski, one is reminded of Mahatma Gandhi’s exhortation to “be the change you want to see in the world.” For Orbinski, doing nothing is an unacceptable response to injustice.

On the other hand, doing nothing has been Canada’s only response so far to the threat of global warming. In “Smoke and Mirrors” (p. 30), writer John Lorinc interviews U of T professors in economics and law who argue that it’s time for Ottawa’s policy of inaction to change. They weigh the pros and cons of carbon taxes and other strategies for reducing greenhouse gases, and conclude that Canada ought to impose a national carbon tax, consider road tolls and “congestion pricing” to make it more expensive to drive, and invest more in public transit, particularly buses. The European experience suggests that a low-carbon diet does not wreak economic havoc. Canada should give the diet a try.

We also fare poorly on comparisons of how we prepare our citizens for the global knowledge economy. Although Canadians are more likely than citizens of other OECD countries to attend community college, we are strikingly less likely to attend graduate school. Twenty years ago, Canadian universities received $2,000 per student more from governments than their American peers. Today, they receive, on average, $5,000 less. In publications per professor, one measure of research productivity, Canada ranks fourth in the OECD, ahead of the U.S. and Japan. But among individual North American institutions, Harvard University still leads the way by a big margin; California’s public universities – UCLA, UC Berkeley – also fare very well.

How do the Californians do it? By deliberately and strategically concentrating graduate education at the 10 University of California campuses. Professors at these institutions have won 50 Nobel prizes – 18 since 1995. Canada, in contrast, exports many potential Nobel Prize winners and sometimes imports winners from elsewhere, but rarely grows and keeps its own Nobel laureates. The last three were U of T’s John Polanyi in 1986, UBC’s Michael Smith in 1993 and, in 1994, Bertram Brockhouse – a scientist affiliated with McMaster University.

There are no quick fixes for our current malaise, but five policy shifts might boost our innovation capacity. First, governments should fund basic research more generously. From lasers to Teflon, countless economically important advances have piggybacked on basic research. And in regions where Nobel Prize winners congregate in great universities, knowledge-based industries flourish in a wonderfully synergistic relationship.

Second, governments need to simplify the mandates of research agencies. Today’s research agencies – especially our three national granting councils – are too often asked to promote commercialization or oversee networks with industry. These expansive mandates dilute scarce resources and distract top talent.

Third, Canadians are efficient at turning dollars into research but inefficient at turning research into dollars. Commercialization is not the enemy of fundamental research; nor is the converse true. However, it is wrong headed to insist that granting councils and research agencies constantly look downstream to the marketplace when their sights are justifiably set upstream on knowledge generation. Instead, we need dedicated commercialization agencies and infrastructure.

Fourth, Canada’s research universities actually lose money with most grants their professors receive. With each grant, the institution takes on new costs for maintaining labs, heating and lighting buildings and providing support services to researchers. That’s why the British government pays an extra 48 cents per dollar of grant payment, while American coverage averages 60 cents on the dollar. In Canada, federal grants cover these critical costs at a rate that is inversely proportional to the total research activity at an institution. Think of it as Orwell without the irony.

Finally, we urgently need more master’s and PhD graduates to spur growth in our knowledge-based industries. But we can’t achieve the necessary expansion in graduate education without a serious rethinking of how we organize and fund our institutions of higher education. Canada needs graduate-intensive universities with the research resources to compete internationally. At the same time we need well-funded undergraduate-intensive universities educating a talented global citizenry. Other jurisdictions such as California have long since recognized that distinct institutions perform these roles best.

Everyone knows that India and China are rising fast. But Europeans, too, are forging new economic and educational alliances with each other. And our giant neighbour to the south will almost certainly reinvent itself to remain a global force. Canada cannot simply do more – or less – of the same in this changing context. We must embrace the spiky topography of excellence and innovation if future generations of Canadians are to thrive.

Sincerely,
DAVID NAYLOR

A research team that included Professor Adam Anderson of psychology, Norman Farb, a psychology PhD candidate, and Professor Zindel Segal of psychiatry used functional magnetic resonance imaging to map changes in brain activity among people trained in mindfulness meditation.

The researchers scanned the brains of study participants as they completed two tasks. Participants were first asked to judge whether word prompts described their personalities, a task designed to trigger rumination (or what the authors call “narrative” thought patterns). In another task, participants were instructed to monitor their reactions to the words without judgment in an attempt to coax them to be “in the moment.”

People with no meditation training showed very little change in brain activity from task to task. They engaged the middle areas of the brain responsible for personality expression and social behaviour. However, participants who had practised meditation used more primitive areas of the brain on the second task.

“This ability to alter brain activity may explain why so many studies show that mood improves with meditation. Taking a break from the middle regions of the brain, which we tend to overuse, might be just what’s needed to help you feel better,” Anderson says. The study results were published in the December 2007 issue of Social Cognitive and Affective Neuroscience.

The study, published in The Journal of Clinical Investigation, provides evidence that when females are exposed to polycyclic aromatic hydrocarbons, the number of eggs in their offspring’s ovaries is reduced by two-thirds.These hydrocarbons are known carcinogens and one of the most widespread organic pollutants.They are found in cigarette smoke, car exhaust, fumes from wood stoves and in charred and smoked foods. The chemicals accumulate in the body’s breast and fatty tissues before pregnancy and are later released into the blood during pregnancy, affecting the fetus.

“While young girls and women may not have thought about their reproductive future, exposure to these toxins now may reduce the fertility of their children,” says Professor Andrea Jurisicova of obstetrics and gynecology, lead author of the study (which is based on an animal model) and the Canada Research Chair in Molecular and Reproductive Medicine at the Lunenfeld Institute.

The reduction of eggs in a woman’s ovaries can lead to premature menopause, which not only limits reproduction but is also associated with osteoporosis, heart disease, stroke and depression.

Although artificial opals are similar to the naturally occurring gems, Arsenault found that it is possible to stimulate the artificial kind electrically to change their colour. By integrating them into a layer of millions of tiny silica spheres, Arsenault was able to manipulate them to produce the entire light spectrum, including ultraviolet and infrared. Once you can do that, says Arsenault, it’s possible to arrange artificial opals into a display similar to the liquid-crystal screens found in millions of laptops and televisions. “It wouldn’t be too different, in terms of construction,” he says.

Unlike LCD screens, which require a bright backlight and a series of tinted filters to produce colour, artificial opals are inherently coloured. This means that the display would only require power when the image is changed. The rest of the time, it would be stable – just like ink on paper. The applications for such an invention run the spectrum from novel anti-counterfeiting technologies, to high-resolution digital paper, to billboard advertisements that could change their message in less than a second. Arsenault says such products are still years away, although Opalux is likely to have a basic version of the technology on the market in the next year or so. At the moment, photonic crystal displays don’t react quickly enough to display full motion video, limiting their use to static displays such as posters and signs. But the research continues, and these limitations will likely be solved in the future.

Arsenault is not the only one who believes he’s on to something big; last fall, he won first place in the Innovation Challenge Awards, a prize given out by the Natural Sciences and Engineering Council of Canada for identifying commercial applications for graduate research. Opal appears to be one rock that’s on a roll.

To Daniel Wigdor, a PhD student involved in the computer science department’s Dynamics Graphics Project, however, the iPhone’s technology isn’t all that new. Wigdor and others have been researching touch screen computer interfaces for years. Now, he and his collaborators have helped develop a semitransparent, two-sided device that allows users to type on a virtual keyboard with all 10 fingers instead of just one, crop and resize photos and perform other tasks. Because the unit is partially transparent, it avoids what Wigdor calls the “fat-finger problem,” which affects touchscreen gadgets such as the iPhone. In these devices, the on screen item being touched disappears behind the user’s finger. Wigdor’s unit allows users to view their fingers in shadow, as if seeing them through an opaque screen. Small dots, called touch cursors, hover over the fingers to indicate the point on the screen that the user is about to select.

Wigdor and his collaborators at Mitsubishi Electric Research Labs and Microsoft Research have created a usable prototype, but the technology – which they dubbed LucidTouch – is not yet ready for public consumption. The device relies on an attached webcam to relay images from the other side, and Wigdor hopes to fix this problem by embedding sensors in the unit. He’s not sure when the invention will become widely available. “The question is whether there’s a company interested in bringing it to market,” he says.