James Maskalyk on Health, Consciousness and Life

James is a physician and author, who practices emergency medicine at St. Michael’s, Toronto’s inner-city hospital. He is an award winning teacher at the University of Toronto, a founding editor of the open access medical journal Open Medicine, and director of a program that works with Ethiopian partners at Addis Ababa University to train East Africa’s first emergency physicians.


He is also member of Medecins Sans Frontieres, an organization for whom he has worked most recently in Dadaab Kenya, home to the world’s largest refugee camp. He was MSF’s first official blogger, and his reportage from Sudan formed the backbone of his first book, the international bestseller, “Six Months in Sudan.” He is now working on his second book, “Life on the Ground Floor,” due out on Double Day in 2017, that will explore the early days of emergency medicine in Ethiopia.

He practices and teaches mindfulness at the Consciousness Explorers Club in Toronto, and is passionate about its potential to encourage personal and social change.

Photo (above): “Six Months in Sudan” Photo Credit: James Maskalyk 

Could you describe some of the biggest lessons you’ve learned from your experience as a doctor for MSF in Sudan?

James Maskalyk: Two come to mind: the first would be that when your heart is speaking to you, do not miss an opportunity to listen to what it is trying to say. By that I mean that although I could tell what I was feeling say, with regards to one of the babies that I had as a patient and deeply cared about, Aweil, who figures so strongly in my book, I wasn’t really listening; I wasn’t really there for it. What I told myself intellectually was that I was transferring my feelings of being overwhelmed and that wanting to help her, particularly her, was a way to remedy a sense of helplessness. It wasn’t just what I was telling myself, it was what other people were telling me. While some of it may have been true, my heart was just telling me to do as much as I could for this girl- to not hold back. I did, and it was a mistake. I thought holding back was going to help one of us, but it helped exactly neither. I still think of her all the time. She’d be about 9 and I don’t even know if she’s alive. And it’s a shame, one of the great shames of my life. I didn’t know how to listen to something that was coming through loud and clear, so instead of exploring it, I shut it down. I try not to do that anymore, and that was a lesson for me to learn.

A second lesson would be about how to live your life. If I could go back to Sudan, I would have tried to find joy more in my day, not take it so seriously, learn some of the language, make friends, and deepen my experience. Life is measured by how often you’re able to engage with what is happening in front of you in a real way. So I think that I would try to live a little bit more in solidarity with the people. And that’s something that I feel I’m able to do better in Ethiopia. I learned in Sudan that I was working and recovering and I didn’t realize that another way to make it easier was to go deeper.


In the Photo: James Maskalyk and his team in Abyei, Sudan. Photo Credit: Flickr/James Maskalyk

When did you start realizing the importance of self-care? Were you always attuned to your inner self or was this more of an awakening as a result of your field experiences?

J.M.: Before my mission in Sudan, I was engaged with it from a way that was outside-in, so I thought things like, “I’ll do half an hour exercise a day,” or eat well or try to get 8 hours of sleep, but actually would try to shut off from my experience. It was the illusion of taking care of my body, while at the same time abusing it, drinking or smoking then feeling bad and trying to make up for it by running twice as far the next day. I was aware of self-care but not in a way that mattered because I was not treating myself very gently. It wasn’t borne with a deep sense of actually caring for my body or spirit because I loved it. It was another task to add amidst a dozen more. I had to slow down to look at it differently. As I have, I have noticed that it is an emergent phenomenon- something that happens from paying attention to what actually nourishes me. For instance, I know it matters that I see my family and my friends so I spend more minutes of my day trying to get in contact with people I love. It gives me energy and helps me feel centered. I’m learning, and I don’t know if it’s age or practice.



Why do people not give themselves the love they give others?

J.M.: That’s hard.  First, let me say, I can only speak from my experience and my experience isn’t always exactly clear, let alone true for anyone else. So why do I do not give myself the love I give to others? Well first, I would say that I can’t give others love when I don’t give it to myself. I can give the appearance, or pretend, but it’s not the real thing somehow. So why don’t I show myself love? Well… it’s easier somehow. There’s a natural negativity bias in my thinking. My talking mind is conflict-oriented and there are times when I confuse it as the main part of my existence. So by getting stuck in my talking mind, which is ceaseless in its opportunity to provide criticism, I can forget that it’s just a tool whose job it is to point out things that could be better. That has served humans in a brilliant way, by allowing us to accomplish some really great things, but it is at the expense of feeling contented or at ease a lot of the time- at least for me. You can get past it and the more we know it is a software program running on our brain’s hardware, the less convincing our self-criticism becomes. I’m not immune to it, that’s for sure. I don’t presume to know about you or anyone else, but its difficult to look in the mirror and see reflected back to you all the beautiful things you are, rather than the vastly greater list of things that you aren’t.

But, I think that’s where activism begins- loving what you, and everyone you are fighting for, is made of. If you can’t do that how can you pretend to care for someone else? It becomes another form of conflict. Caring for yourself is a necessary prelude to caring for others.

What was it like when you re-discovered joy, with friends, several months after your MSF mission in Sudan?

J.M.: A reminder that moments like that are rare, but they are why I am here, and that I shouldn’t get confused thinking that I don’t deserve it because others are hurting or the world is too messed up. It showed me how foolish I was- that in fact, I was doing the work for the wrong reasons or from the wrong direction. If given the opportunity I should embrace joy and happiness when they are on offer, because the world simply needs as much of it as possible. It’s the direction that we need to hold.

At the same time, I can’t make it an expectation that anytime I’m not having a peak experience of happiness I’m having a lesser experience. You’re never further away from happiness than when you think that what is happening would be better if it was different, because that’s the only thing it will never be. Even though the experience I recount of joy after Sudan was particularly sweet, I think that if I only wanted to live in that sweetness I’m not sure that it would open itself to me again as easily if I didn’t work on being OK with all the times when I’m not surrounded by friends, where I wasn’t feeling warm at and ease.


In the Photo: Abyei Basic Boys’ School, Sudan Photo Credit: Flickr/James Maskalyk 

You mention, in a public talk about self-care, internal versus external pain. Why do you think that some people turn to external pain when their internal pain is too strong?

J.M.: I think they’re doing the best that they know, but they’re caught in a lively but vicious inner world that has become the dominant aspect of their experience and they don’t know where else to turn. Let’s  talk about addiction and dangerous behaviors as forms of external harm. If you look at a lot of the research about addiction, and this may be a surrogate for other types of self-harm, a lot of these people share a common experience of childhood trauma where at some level of their experience they felt a moment of hurt and they weren’t given the skills or opportunity to integrate and heal. My impression is that they have a pain inside of them that they need to address and they don’t know how to do it. They get some freedom initially from drugs or booze, and it probably takes them to a place that was, at least temporarily, better than the one they were at somehow, but it doesn’t get them there and trying to treat a trauma with something that makes you sicker creates its own problems.  Sadly, the way we deal with addiction in our society is by making it seem like a problem in itself, rather than looking more deeply at the wound it is trying to cover up. It’s a spirit trying to heal itself, but they’ve lost the community and the tools, and it’s hard because we tell them that if they stop drinking or hurting themselves or if they get out of that relationship, they’ll be better, so they try and they get help and some of them stop, but the hurt is still there and many of them start again. It’s important to have that pain. It’s the universe telling us something very vital, pointing at exactly where we have been injured. It’s like having a hurt ankle. Unfortunately, at least in western medicine, because we are so focused on the body we don’t have good language or treatments for the internal kind of pains.

You’re never further away from happiness than when you think that what is happening would be better if it was different, because that’s the only thing it will never be.

Why do you think that people hold onto hurt rather than letting it go? What have been the effects on you of letting go of some of what you have lived?

J.M.: The answer for me is because it’s easy. In the true sense of the word, it is second-nature. At first, the pain, whether real or imagined, hurts. So you notice it. Why? Was it my fault, or someone else’s? How do I avoid being hurt again? Often, it is not quite clear so we make up a story that fills in the gaps and where we are the victim or the architect. With time, it becomes what we know, our identity- who we are, even. And then, even if we have mined the misery to its last lesson, we hang on because if we lose it then we lose something of who we are, our identity. The next step is taking responsibility and that is a hard one. Sometimes it’s easier for me to sidestep my own agency, but letting that pain go is the greatest blessing, and it doesn’t mean that you lose any of the lessons, or let myself off the hook for things or run from pain in the future. It’s the total opposite. You give yourself permission to feel the pain, and the same permission to let it go.

You talk about being able to help yourself enough so that you can help others from a “place of infinite resources.” Could you describe what you mean by this and how you think you can reach that place?

J.M.: What I mean by that is doing it from a place that will sustain itself. One of my teachers talks about it as a difference between will and willpower.

Willpower is what will make you work the 24 hours straight in a row, teeth-gritting determination. It’s exhaustible. Will is a lot softer yet more powerful. It is that place of infinite resources where you say, ‘I’m going to do this work because it is valuable and I believe in it, and while the way I go about doing it might change, it is a natural expression of the things I hold most dear.’

Parents, most of the time, care for their children not by willpower but by will. Though I’m sure they use both on occasions.


In the Photo: James and Aweil in Abyei, Sudan. Photo Credit: Flickr/James Maskalyk

You speak about having faith that every individual deserves to be free. What does freedom mean to you?

J.M.: It depends what context I’m speaking about it in. I most often mean peace. Internally, for me, it is being available completely to my whole experience, deeply accepting of it, not pushing away anything or hanging on to anything. That would be my version of a personal freedom. Not being caught in ideas about the past or the future or living or dying or love or hate, and being able to respond from that place. Then there’s kind of the more obvious external freedom from what we see in the world. An absence of people dying in war and in fear, people living in war and in fear. That’s easier to see, but the two I think are linked. What you see as external signs, the opposite of freedom, are conflicts that live in the hearts of people and made manifest in the world.

What is your life philosophy? What do you live for?

J.M.: I’m not sure if I have one, exactly. I know I want to be available to as much of the experience of being alive as as possible. That means joy and sorrow and peace and war and love and heartbreak. All of it. Then learn how to be OK with letting it all go. I also believe that, to some extent, while the world happens to us, it also happens because of us and with that agency comes a certain responsibility. So as I work on that place inside of me, create conditions for my own happiness, it feels natural to have those actions extend through my work into the world. The only world that really makes sense to work towards is one where no one starves, where no person is hurt by another person’s unwillingness to deal with his own anger, where no one’s killed for reasons as arbitrary as money and false discriminations on race. You know, that same thing that we talked about before how we can believe that we aren’t enough and there isn’t enough and that false belief gets multiplied so many times. I think it is in our destiny to get past this, and in some ways we are, but it’s deeply saddening to see the many people who are dying from the conflicts that seem necessary for us to get to that place.


There is a lot of research about the effects of placebos. For example, there was an experiment where people with cancer were given a chemotherapy placebo and around 30% of those people actually lost their hair. What are your thoughts on this and on the psychological power of healing?

J.M.: Placebos are one of the most interesting aspects of medicine. It proves that the differentiation between mind and body is a false one, because they are deeply connected. It makes intuitive sense. If I hurt my ankle, that pain affects my mood, and my mood will in turn affect that pain. Not just pain, but my immune system, my hormones. The whole system can be influenced. If I tell a patient that I care about them and give them a pill to help them, there is more to the act than the active ingredient of the chemical. It is the belief they are being cared for that softens the distress. For me it is one of the reasons it is important to maintain integrity in medicine because it contributes to our effect as doctors. Being trustworthy and looking out for a patient’s best interest is an effect in itself- on people, on society. So having conflicts, or being dishonest about our intentions, loses that effect.

Looking toward the future, you will soon be releasing a new book. What is it about and what message do you hope to get across?

 J.M.: It’s called “Life on the Ground Floor,” and it will be out in January 2017. It’s about emergency rooms and principles behind them, as seen from Canada and Ethiopia. Emergency medicine has its particular logic that I believe strongly in: the sickest gets treated first and everyone else in the order that they arrive. Hey, maybe that’s my life philosophy. Rather than exploring differences, it shows what is at the core of good medicine, though you can imagine the type of care you are able to deliver greatly depends on what resources are at hand. Why that title? It’s because ERs are always on the ground floor, because we take everybody.

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Featured Image:  James in Abyei, Sudan. Photo Credit: James Maskalyk

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  1. Claude Forthomme

    Thanks for an excellent interview. I’m looking forward to his new book “Life on the Ground Floor” (certainly a logical title: all ER takes place on the ground floor) and the implied philosophy that book explores, he says: “Emergency medicine has its particular logic that I believe strongly in: the sickest gets treated first and everyone else in the order that they arrive.” That, I believe, is a fundamental principle governing all humanitarian aid (that I have ever seen in my work for the UN), the sickest, the most vulnerable get attention first.

    In fact, this principle should govern development aid too though it is rarely highlighted: it makes sense (a moral duty really) to go to the deepest pockets of poverty in any society since there is never enough funding to help everybody.

    Unfortunately, there have been times when the concept of development aid has rested on the idea that since you should show success for your projects to entice donors, you had better start in the places where aid would be “easier”, where the “premises” were promising (for example: political stability is in place, corruption is relatively low), where you could show “early results” to encourage future funding. Not an entirely wrong reasoning, pragmatic perhaps but not a particularly attractive one on a moral level!

    • Chloe Hogg

      Thank you for your comment, Claude!

      I certainly agree with what you’re saying. Rather than serving the people that need it the most, aid agencies often focus more on easy and high-outcome projects to entice their donors. But the limitations do not end there. Even if we were able to re-structure the aid approach so as to help the sickest/poorest/most in need first, prioritizing this over attracting donors, the agencies still run the risk of wrongly assuming HOW to help those sickest/poorest/most in need people. It is a complex industry that has done a wonderful job at helping pull vulnerable people out of pain and poverty, but that at the same time has left behind a lot of damage, and that continues to do so today. We need to change that. Having profound individuals like James Maskalyk in the industry seems like a brilliant way to start.

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