Lessons From the Frontlines of Humanitarian Crises: Dr. Joanne Liu, Former International President of Médecins Sans Frontières and Author of Ebola, Bombs and Migrants

Lindsey Smith 

Hi, I'm Lindsey Smith, welcoming you to Raise the Line with Osmosis for Elsevier, an ongoing exploration about how to improve health and healthcare. Today, I'm honored to welcome Dr. Joanne Liu to the podcast. Dr. Liu brings decades of experience on the front lines of humanitarian crises around the world. We'll draw on her unique perspective to better understand the challenges we face now and those that lie ahead.

Dr. Liu served as the International President of Médecins Sans Frontières --also known as MSF, or Doctors Without Borders -- from 2013 to 2019. During her tenure, she led responses to major humanitarian and health crises, including the 2014 Ebola outbreak. She shares powerful insights from these experiences in her new memoir, Ebola, Bombs, and Migrants.

Dr. Liu is currently a professor at the School of Population and Global Health at McGill University, where she also directs the Pandemics and Health Emergencies Readiness Lab. In addition, she serves on the World Health Organization's Independent Panel for Pandemic Preparedness and Response.

Dr. Liu, thank you so much for joining us today. 

Dr. Joanne Liu

Thank you.

Lindsey 

I'd like to kick off this interview with learning more about you and what first got you interested in medicine, specifically pediatric emergency medicine.

Dr. Liu

I basically decided to go into medicine after I've done a stay in West Africa. I did some international cooperation with Canadian Crossroads and I stayed in Mali for three months. After I came back, in terms of what I saw for needs in the general population, I decided that I will go into medicine and work overseas with, I would say, the most vulnerable population or people in times of crisis.

Lindsey 

And how did you land on pediatrics?

Dr. Liu

So I remember when I was working overseas and I said, oh, there's so many children here. And I just said, I should not run out of patients. So I always thought that as well, when I did medicine, they were about the best patients you can have. A, most of the time they recover very well with no sequela, and B, when they're not sick, they start to play and eat. So I thought it was pretty easy compared to adults.

Lindsey 

That's amazing. Thank you so much for sharing how you got into medicine. And I understand that you knew at an early age that you wanted to eventually join MSF. Can you talk a little bit about that?

Dr. Liu

Sure. I think the seed was planted when I was reading as a teenager, doing my quest for meaning in life, different books. One of the books I read was about a surgeon working with Médecins Sans Frontières, Doctors Without Borders, MSF, in war zones. I remember when I read that, I said, wow, this person is making a difference in the most improbable situation, in most improbable site and context and I thought that was very, very interesting. 

And then I read another book that really stayed with me and that I really love, which is The Plague by Albert Camus. I remember in the book, the doctor was trying to care for a patient who had plague was asked, “What is driving you? Why do you keep on?” The doctor hesitated and the questioner continued, “You know, all your patients die. You don't make a huge difference and in addition, you don't even believe in God.” And then the doctor said, “I never got used to death. I don't know more.” And I remember when I read that telling myself I will never trivialize death and I will fight for life. So. medicine became a very simple answer to my quest.

Lindsey 

Thank you so much for sharing that personal story. And I love that those books inspired you. Let's dig a little bit more into your involvement with MSF. I understand that since 1996, you've been involved with it went on to serve as the international president for seven years...a remarkable journey indeed. But what motivated you to take on that leadership role at that global level?

Dr. Liu

Well, I think that I have done a fair amount of field assignments. At one point, I noticed that the Médecins Sans Frontieres movement was really growing and I was concerned that basically the infrastructure or the offices in the global north were almost growing faster than our operations in the field.

So, I figured out that I wanted to make sure that we don't lose the essence of MSF, which is actually bringing medical aid in the worst and hardest and toughest places of the world. So that's what I wanted to make sure that we don't lose in the process of modernizing our support and increasing the places where we were doing fundraising and as well hiring for international staff.

Lindsey 

Your willingness to step into some of the world's most challenging environments. I think says so much about your courage and your commitment to humanitarian care to really kind of create that deep purpose of meaningful change. So thank you for all of your work there. I want to talk a little bit about your book Ebola, Bombs and Migrants and what was the inspiration behind that book to and talk about some of the key themes that you hope the readers take away from it.

Dr. Liu

Thanks for the question. Yeah, the book...it's been a long journey, like anyone who has written a book, I guess. This is what I call sometimes FBI. In French, we say, “fausse bonne idée” -- it's a good false idea in the sense that you think it's going to be good, but actually it becomes a big, big thing, and so it took me a while to put that together. 

But I think what pushed me to do that was the fact that when I was the international president, things went so fast that I had the feeling that I didn't have a chance to somehow reflect on what happened and really harness all the lessons to be learned. And so I just said, well, to just somehow get over the hangover of living within myself, I would write a book and reflect. 

I would say that the premise of the book is I think that since September 11, 2001, we live in times of fear. Fear has brought what I call the security obsession and our security obsession is actually eroding our solidarity mechanisms in the world. And by eroding our solidarity mechanisms, when we come in response to crisis, we respond late. I bring three cases.

The Ebola outbreak in 2014/2016 in West Africa when we only answered when we felt threatened as the global north. The attacks on hospitals where we see the enemy everywhere and we are basically violating the international humanitarian law. And the migrant crisis. Today we portray migrants as an existential threat to our identity, to our economy.

Lindsey

I think what I noticed in the book is that it's a reflection on the past, also some learnings and a call to action and the key themes that you highlight -- Ebola, the attacks on hospitals and the migrant crisis -- are all deeply relevant, especially in today's world. 

So let's talk a little bit more about the Ebola outbreak. Can you describe how your team was often overwhelmed by the sheer number of infections and lack of effective treatment at that time? And maybe just take us back through that time period and how countries were responding and some of the key challenges that you faced to try to drive a more effective response.

Dr. Liu

Right. So the Ebola outbreak in 2014/2016...I think we have to bring ourselves back to those times because back then there was no vaccine or there was no specific treatment for Ebola. And as a reminder, Ebola is a hemorrhagic fever and 50 to 70 % will die if they get infected. 

So, what happened in West Africa, it was the first time that we have such a massive outbreak. The biggest one before that was in Uganda in 2000, where there were 400 cases, 200 survivors. In 2014/2016, there were more than 27,000 people infected and 11,000 people died. So, it was massive. What happened is because of such a high case fatality rate, very few people, very few organizations kept the know-how of how to treat people with hemorrhagic fever. We kept it at MSF because we were dealing with all sorts of different outbreaks of hemorrhagic fever from Marburg to Yellow Fever and Ebola. 

What became clear after a while was the fact that we didn't have enough beds for Ebola. And the importance of having an Ebola bed, as we used to call it, is the fact that a patient needs to be isolated. Because if he's not isolated, then he will stay in his family and infect other people. And so it was preventive as well a bit curative because back then they didn't have specific treatment. It was only supporting treatment. 

Very early on we realized that all the centers were overwhelmed: the one that MSF was running, but also the ones that the different Ministries of Health were running in the three countries affected. At one point we realized we needed more hands on the job. And one of the toughest decisions that was made in late summer 2014 was to take one of our best elements in each of the center that we were running and then taking them and put them in a training center because it was the only way to scale up the number of people with know-how about treating patients. So, that was one of the tough ones. 

The other very tough decision was every time we were briefing someone, we just say, you're going to West Africa, but the reality is we might not be able to medivac you if you are sick from Ebola or from any other illnesses because nobody wanted to take back people in their country right away. They wanted them to be in quarantine for three weeks. Sometimes people were being kept in a country they would stop over somewhere. So that was a challenge as well.

And the other one was the fact that, I would say, a whole region was falling apart. Like I said in the speech that we have written for the United Nations General Assembly, we cannot let people die on their own. We need to run in the burning building and go in and save people. And that was the call we made in September 2014 to the rest of the world.

Lindsey 

Thank you for walking us through that time period where we had no vaccine, no treatment at the time combined with the high fatality rate. I think your account really underscores how critical leadership is and the coordination -- like moving people to different training facilities -- and the early action are so important in global health emergencies. 

I've heard you say before that while new pandemic threats are inevitable, whether they turn into a full blown global crisis often comes down to political decisions. And so I want to ask you, do you think that we learned what we needed to from past outbreaks like Ebola? And did those lessons improve our response to COVID-19? And then looking ahead, do you think we're any more prepared for the next pandemic that's to come?

Dr. Liu

Well, I'm part of the WHO Independent Panel for Pandemic Preparedness and Response and one of the key top-level messages that we always put forward is pandemics are a political choice. We will not be able to prevent an outbreak or an epidemic somehow, but we can prevent an epidemic from becoming a pandemic. That's a political choice. It's to basically take over the epidemic where it is with quick and early action instead of waiting for it to spread, like what  happened in West Africa, to fester and become out of control. 

With respect to Ebola, what is great – and people seem to forget -- there was huge legacy from the Ebola outbreak in 2014-2016. One of the biggest ones is that people realized that we were not ready collectively. People were ready to go and send money, but what they were not ready was to go and give hands-on help if necessary. They just said, you know what, we’ll give you money, you take care of it, don't bother us, don't bring Ebola back to our home. And then people realized that that was not good enough. 

So they said, my God, if there's another type of scenario like this, what are we going to do?

One of the things that we did back then -- which is one of the big, I would say, legacies of the Ebola outbreak -- was what we call the research and development blueprint of the WHO, which basically gave the way forward on what are the different viruses that have potential to become a pandemic, and for which do we need to develop what we call medical countermeasures to fight them. So, that was one of the things. 

But the other thing that came very, very clearly obvious to everybody was we need to be sharing new knowledge in a timely fashion, in real time. This is what happened with COVID-19 to a certain extent, with the sharing of the genomic sequencing really early on in January 2020. Now people say that, yes, we need to share the genome sequencing early, but we also need to share in real time the discovery as we are making them in order to fast track discovery collectively, as well get a new medical countermeasures, be it a diagnosis, a treatment or a vaccine. 

So I think this was learned. I often see that we have some difficulty in learning because this is obvious, but we don't implement it, you know, as it should be and so I think that this happened partly for COVID-19. But as well, the understanding as applying what I call the precaution principle did not happen with COVID-19. We were such in denial. I thought it was very surprising that it took a long time for WHO to acknowledge it spread with aerosols and so therefore we should wear N95 masks.

We learned as well that the leadership of the WHO in those instances, and giving guidance in a timely fashion, is absolutely essential for the planet. So we learned a lot of things. Will we be able next time around to fast track everything we did for COVID-19? This will be my last point on this. It took six months to declare a public health emergency of international concern with Ebola in 2014-2016, but it took only six weeks for COVID-19. So yes, we're learning.

Lindsey 

I think it's encouraging to hear where the progress has been made there with the blueprint of sharing information and the discoveries in more real time, but also a realization that gaps might still exist with the implementation and the timely guidance. So thank you so much for sharing your insights on that. Also in your book, you talk about the attacks on medical facilities during your tenure, especially the bombing of an MSF facility in Afghanistan in 2015.

After that, you led an effort to pass a UN Security Council resolution on the protection of patients, clinical providers, and humanitarian personnel in armed conflicts. But this still seems to be a problem. What is preventing an end to these attacks, do you think?

Dr. Liu

Yeah, that's the question of the hour. Thank you very much for that tough question. I think that one of the reasons we decided to talk profusely and publicly about the attacks on Kunduz on the 3rd of October 2015, was the fact that this attack was a bit different from the others. There was an insistent aspect to it...five airstrikes on the principle building of our trauma center in Kunduz in the northeast area of Afghanistan. So what was interesting is although we had given our GPS coordinates, although we were in contact with all the different parties at war, we were not able to unplug what was happening. 

We called everybody, we called the Pentagon, we call the Allied coalition, we called the Taliban. We called everybody, and we just could not stop it. And so what became clear to us is to say, practically speaking, we need that kind of “red phone” if something happened. But in addition to that, we need to get a political signal that there's still rules of war, that it's not a free for all, and that we would try to spare the civilians. 

Today, we seem so far from when we passed the resolution on the 3rd of May, 2016. It was unanimously voted by the Security Council and eighty countries backed the resolution. But as I'm speaking to you, every day or every other day, there's medical facilities being bombed. And I think why it’s happening is because we are letting it happen because there's no political costs. 

If there were political costs -- if people were holding to the international humanitarian law and then we tell people you have to stop and there are consequences if you do not respect this -- I think there will be a little bit more compliance. But when we let full impunity reign, what can you expect? 

In addition to that, I always say – and this ties in with the third topic of my book on migrants -- if you let total war to happen, not sparing the civilian, you cannot be surprised that people are fleeing. People will flee if they don't have a place to hide. If they don't have a place to be cared for, if they don't have a place to heal, they're gonna flee.

Lindsey 

It's heartbreaking that those risking their lives to provide care still aren't truly protected. I think it highlights the gap between policy and actual protection on the ground. On the second part of your answer, you touched on my next question. The other major subject in the book is the refugee crisis, which started to be felt more acutely in Europe during your tenure, but which has obviously continued to grow over the years and it’s something we're still seeing today.

What's your assessment of how nations have responded to the ongoing crisis and what should they be doing differently?

Dr. Liu

Well, it's interesting because the phenomena of people moving around is something that has happened since the beginning of time. People do that for survival. That's normal. Animals do it, too. So, what happened is there were record numbers in 2015, and some of that was linked to the war in Syria.

But it was, I would say, tagged as a “crisis” because basically people were knocking at the door of Europe. There's been other places where there have been massive displacements, but when the Global North gets affected, then it becomes labeled as a crisis. But, it's true that there are record number of migrants -- meaning living outside the country where they're born. There's also about 120 million people that are in what we call forced displacement for different reasons. They might be fleeing violence, or they might be fleeing persecution or famine or economic issues or natural disaster. But it's there, it's real, it's happening. 

And the reality is, as I said earlier, the way we wage war will make a difference because if we were sparing the civilians in war zones, I think that will at least decrease a certain number of those people in forced displacement. I think that it's how we felt our responsibility and solidarity for countries who are struggling, because a lot of people talk about what we call the “pull factors” -- what attracts people to come -- versus the “push factors”  

But if we don't fix the push factors -- which are the violence, the insecurity, the economy, the lack of economic opportunities -- people will continue to flee. Many migrants say, you know what...it's better to be somehow illegal in a high income country and get money by cleaning houses or taking care of a garden than living under the bomb or under the cartel violence in some countries. When you hear those stories firsthand, you understand that people leave because they have no choice. It’s about survival.

Lindsey 

I think the pull versus push factor that you mentioned is a really important point here, and that nobody leaves by choice. I want to switch gears a little bit and talk about the systemic causes underlying humanitarian crises and the inadequate response to them. First of all, do you think that there are systemic causes underlying humanitarian crises? And do you think the response that has been given thus far has been inadequate.

Dr. Liu

Well, that's a bit out of my area of competence, about the systemic causes of crisis. By definition, being a humanitarian aid worker is about responding to the need of people, and you don't go into the causality of things. But of course, we do see that some of our way of living and economical predation has a cost on some more vulnerable population. And so we are part of the problem to a certain extent. It's not only that they have a problem. We collectively have problems and we would need to address them collectively. 

Right now, the circumstances are pushing us to do that just because of climate. Everybody is responsible for the warming and everybody's gonna need to do something. We cannot do something only in one corner of the planet. Collectively, we're gonna need to do something to decrease the speed of the global warming of the planet. If we don't do that, then every day we will have heat waves, we will have wildfires, we will have all sorts of different natural disasters that will basically exhaust our capacity to respond.

Lindsey 

Thank you for sharing your perspective of what's getting in the way of a stronger, more effective response when these crises do happen. I agree we collectively have a problem on a lot of these issues. I want to talk about an interesting question that we have for you in the humanitarian health field, about aid organizations maintaining their neutrality to preserve access to care versus publicly advocating for certain steps to be taken to make providing that care easier or more effective, which could provoke a negative response from the political entities involved. What are your thoughts on that?

Dr. Liu 

Well, I think that in some circumstances, what I have witnessed is that the excuse of neutrality has been put forward in order to not act or in order to not name things. At the end of the day, I think we have to be careful. One other thing I used to say when I was international president, and I still say nowadays, is if your operational principle of neutrality, independence and impartiality is preventing you from treating a patient, you should go revisit and reflect a little bit on your principles. So that would be my little piece of advice on that. 

I'm a humanitarian aid worker, as I said, and I respond to the needs of people. The basic principle is we care for both sides of a conflict. What is happening nowadays, because of asymmetric conflict, sometimes you only work on one side because the other side doesn't need help or it doesn't want to have any support or help.

Lindsey 

That's a really important perspective on neutrality, and I think it highlights the tightrope humanitarian organizations have to walk while trying to protect access while also staying really true to their values. So thank you for sharing that. 

Also in your book, you relay experiences you have had providing care for young people who tell you that they have no hope for their future and don't want to have children given the state of the world. Tell us about that and your response to them in those difficult moments.

Dr. Liu 

Thank you for this question. It's actually interesting because I'm a pediatric emergency physician and I started working in the ER more than thirty years ago. What is clear to me is when I started, children being in distress by what is happening to them was seldom. I would get one case a week. Now per shift, I get between two to four cases of kids who tell me, “I don't want to live. I don't want to have children. I cannot project myself in the future. There is no future. You are handing over to us a planet that is not working.”

So one of the reasons why I wrote this book was the fact that I wanted to tell those young kids, listen, we've tried. And of course we're not handing you a perfect planet. The planet is really sick. On the other hand, we try and I still think that it's worth trying even if what you're going to bring forward would be an imperfect solution. I always say that an imperfect solution is much better than no solution as long as you're not complacent with this solution.

Lindsey 

Your ability to hold space for those feelings also serves as a reminder that sometimes the most important act is empathy. I think I heard a lot of empathy come out in your answer there to listen, to witness someone's pain, to let them feel seen and heard, and maybe not have the right answers or a perfect solution, but being present with them and reminding them that they're not alone.

Dr. Liu 

Well, every time when I see those children in my ER, I just tell them to hang on and give it a try. I just say that it's better to fail while trying than to fail for not doing anything. It's the way I am. I'm a person who is always in action. So that's what I hope I'm going to transmit to the next generation.

Lindsey 

That's a great tie in to our next question. So at Osmosis, we have many students and early career health professionals in our audience. You offered some good advice already throughout this podcast, but I wanted to give you an opportunity to give them more advice about getting involved in humanitarian health work during their careers.

Dr. Liu 

I think that they should get involved. I don't think that being involved at the frontline of a conflict is a fit for everybody, and that's fine. But I think that everybody can contribute from where they are. There are no big or small contributions...there's only contribution as far as I'm concerned. I think that all of us can do our little bit to make things a little bit better around us. 

So what I wish them is to have the strength, the lucidity, and this sort of kick-ass spirit to move things around and get it better.

Lindsey 

I love that. And I've heard you say before that every patient has something to teach us. So we wanted to share that little nugget of advice as well. and then just recap that, you know, you might not need to be on the frontlines, but there is some way somehow to contribute today. So thank you so much for sharing that to our audience. 

Before we wrap up today's episode, I just wanted to give you a chance, to maybe touch on anything that we maybe didn't cover that we should have.

Dr. Liu 
Well, I really do think that today it's easy to want to give up. And my last thing is just say, don't give up, just give it a try. Often you might not see the result of what you're doing right away but you will have moved the line a little bit and allowed the next person to continue. This is how we change things. 

You know, when I started in medicine, people were smoking in my hospital during ward rounds. There were an ashtray in the hallway. Now, you can't even smoke around the hospital unless you are eight meters from it. So, things change. It just needs a little bit of patience, but no complacency.

Lindsey 

Don't give up because that is how change happens. That is a powerful note to end on Dr. Liu. Thank you so much for sharing your time, insights and experience with us today.

Dr. Liu 

Thank you very much.

Lindsey 

Thank you so much, Dr. Liu, for joining us today. During your time at MSF, you led the organization through major humanitarian emergencies like Ebola, championed innovative solutions such as telemedicine, advocated fiercely for the protection of patients and medical facilities in conflict zones, and provided hands-on care in some of the world's most challenging settings. 

With 30 years of experience in emergency clinical care, policy and global health, diplomacy, you continue to inspire us to do more and to do better in an increasingly divided world. We're deeply grateful for your perspective that you've shared with us and the powerful reminder of what's truly at stake. To learn more, be sure to check out Dr. Liu’s memoir “Ebola, Bombs and Migrants.”

I'm Lindsey Smith. Thanks for tuning in. Let's all do our part to raise the line and strengthen the health care system. We're all in this together.