A Planetary Perspective on Healthcare - Dr. Maria Guevara, International Medical Secretary at Médecins Sans Frontières

Shiv Gaglani: Hi, I'm Shiv Gaglani. The background of today's guest, Dr. Maria Guevara, perfectly prepared her for combating the COVID pandemic. Her current work as International Medical Secretary of Médecins Sans Frontières, also known as Doctors Without Borders, is informed by expertise in pulmonary and critical care medicine, extensive experience providing medical care on the ground throughout Africa, the Americas, and Asia, and efforts in global health policy and advocacy. Doctors Without Borders cares for people affected by conflict, disease outbreaks, natural and human-made disasters, and exclusion from health care in more than seventy countries. Dr. Guevara is a member of the Independent Allocation of Vaccination Group for COVAX and previously advised the WHO on outbreaks and emergencies with health and humanitarian consequences. So, Dr. Guevara, thanks so much for taking the time to be with us today.

Dr. Maria Guevara: Thank you Shiv to you and your team for this chance to exchange and take part. I think what you're providing as a service is brilliant. So, congratulations…

Shiv Gaglani: Thank you very much 

Dr. Maria Guevara: …on that and making the magic of medical science so accessible. I just wanted to say I find it quite funny because I used to fall asleep with those medical reference books near my head thinking it would seep through osmosis, but this way is so much more efficient! 

Shiv Gaglani: (laughs)It's funny because there's actually a Garfield comic where he is sleeping with textbooks under his head, and it says "Learning by Osmosis." And that is ultimately the aim, to make learning so easy and enjoyable, that knowledge can just diffuse into your brain.

Dr. Maria Guevara: Love it, well done. 

Shiv Gaglani: So you have a really impressive background, and many of our audience who listen to this are people who strive to have as much of an impact on global health as you have had in your career. Can you first start by giving us and our audience a bit more information about what got you interested in medicine, and then particularly critical care?

Dr. Maria Guevara: I think I must have always wanted to be a doctor, even since I was in the womb of my mom -- who was an anesthesiologist by training -- and my dad was a surgeon. So, I must have been inhaling those anesthetic gasses already. But I remember when they would be taking us to the hospitals to show us around where they work, I would imagine myself in the hospital actually providing care. It's so vivid, really, in my mind. I know I was four years old going, “I'm going to be a doctor.” Why critical care? I think I just really wanted to take care of the patient from the moment they came into the emergency room, all the way, whether they were going to crash and ended up in the ICU or they would be in the internal medicine ward or in the clinics. I just wanted to be able to do that and work with my hands without being a surgeon. So, it was a no-brainer to do that, and I guess at the end of the day, I'm an adrenaline junkie. I think contrary to most Asian families, a parent actually never shoved medicine down our throats. It was really about good education, and they were definitely great role models for that, and I just really wanted to follow in their footsteps. 

Shiv Gaglani: That's awesome. That's very relatable too. My dad's a retired general practitioner, my mom's a physical therapist. So, it's almost hereditary, and that exposure can really have an impact. Not just obviously on your life, but then the work you do with MSF, or the work my colleagues and I have done with Osmosis, on many more people if leveraged in the right way. You've had a really storied career in global health and public health. Can you talk to us a bit about MSF? I know many of the people listening to this have these dreams of working with Doctors Without Borders or volunteering with them at some point. Tell us about your journey with MSF.

Dr. Maria Guevara: Well, my journey first to MSF was actually in that role modeling. I was following in the footsteps of my parents. They would always take their holiday breaks during Christmas for a couple of weeks in the foothills of the Philippines where cleft palate is quite common actually, and now I'm just realizing how common that was really -- about one in 1,000 live births, which is incredible, but it's a reflection of the lack of access to healthcare. They would come back with these pictures of how they fixed, repaired, the cleft lip and palate, and I would just go, “Wow, they're such heroes. I want to be just like them.” 

I know in the U.S. it’s a very capitalist kind of thing -- thinking around medical care and the health systems -- and it wasn't about money for me. It was really about providing service, and so when I was going to the university, I was looking for a way…what would it look like when I became a doctor? Where would I serve? What would I do? My boyfriend back then had this sticker of MSF on his dad’s car and I was like, “What is that? What's Médecins Sans Frontières?” That was before I spoke French. And he was like, “Oh yeah. That's Doctors Without Borders." And I was like, “Okay. One day, I'm going to work with this group that has no borders.” 

When I finished my training and started to practice, I really wanted to join MSF as soon as I finished training and after my fellowship, so I actually signed up and I was -- that'll age me here -- but it was in 1999, just when it was awarded the Nobel Peace Prize. I didn't actually go out to the field until 2004 because my father was sick, and I really wanted to get more training and more practical experience working in private practice, but also in academia. And so I was working at the University of Florida, where I was in a very good job in internal medicine, and then also in the ICU, especially in the anesthesia and surgical care units. It was great, but all of a sudden, I had this kind of choking feeling as I sat in my lovely three-bedroom home, with my jacuzzi and my lovely luxurious car. I just thought ‘if I don't go now, I will regret it my whole life,’ and I literally gave up and said I'm going to join MSF and see what happens. That was eighteen years ago, and I'm still here and I think that's a testament of not only for me, but I think the quality of or the passions that are drawn to join MSF. The people that join MSF really have this kind of calling. Once you're in and you get that bug, it's this incredible virus that just won't go away. 

Shiv Gaglani: Yes. 

Dr. Maria Guevara: COVID jokes aside. 

Shiv Gaglani: No pun intended. I mean that's amazing. That's a great story and obviously aligns well with much of the advice that we've heard on this podcast, which is you regret the things you don't do as opposed to the things you do.  And also this whole concept of golden handcuffs, right? Your life can get so kind of cushy, as you mentioned, that if you don't do something now, you may not find that motivation to take that risk later, and then you'll regret it later. So that's inspiring to hear. I don't know if there was one epiphany or it took a couple of months for you to go and do that, so what was that like then joining MSF and can you talk to us about some of the biggest highlights for your personal career there in terms of where you've been deployed and what you're proud of accomplishing?

Dr. Maria Guevara: So my first job was volunteer, obviously, and I was sent to Liberia right after the “Three World Wars” where there was fighting between the two rebel groups. The whole city of Monrovia and most of Liberia just kind of fell into this conflict, internal conflict, and we were there to try to provide care. I was stationed at the Maternal Child Health Hospital. I'm in adult-only critical care, so I haven't actually seen kids in my training, but there were all these infectious diseases like malaria -- which today is the bread and butter of what we see -- but at that time, I'd never even seen malaria. So, there was this real exponential growth and understanding and this incredible culture shock, and I think the first two months were really challenging to adjust, and I almost was like, 'okay, I'm going back.' 

But then this one day when we had just gone back on a Friday, the whole city locks down because there was fighting everywhere, there were riots everywhere. It took two days for us to actually have a convoy and create this kind of humanitarian corridor for us to get to the hospital we were at, because over the weekend, there was burning of houses and buildings and people. Our Maternal Child Health Hospital became this trauma center where our teams --not necessarily trauma care people -- were just inundated with mass casualties. We desperately tried to get all the MSF people in a row to try to access them. I remember driving in this convoy on this road -- that was so busy just two days before -- with the gas stations burnt down, nobody around. It was that moment you go, “Right, this is why I'm here, and this is why it's relevant.” When we got there, the experienced MSF people were going 'that one's triage,' and I went, 'oh, right. That's what I want to do,’ and I was sold. 

Fast forward to the different moments that I have seen working in conflict. Congo was a very formative moment for me. I was there, maybe, in 2008 and then I was back in 2018, literally ten years later, when there was the Ebola outbreak. It was inspiring, and you just see this evolution of an incredible community and country and yet still caught in conflict and just having to address all kinds of outbreaks right and left, including conflict, including natural disaster. Probably the most challenging of them was in South Sudan. I was in Juba in 2016, where there was a moment when there was fighting on that Independence Day, and I was trying to negotiate access to some cholera samples because there was this burgeoning cholera outbreak in the city. 

I was supposed to meet at the Ministry of Health and they're saying, "Come, come quick!" So, we're driving down the ministry's road and we hit the Parliament and White House, and then you just see like armies lining the road. Literally, with guns facing each other. Then I was like, “Okay, on the way back, go to another road.” Within thirty minutes of getting back, the fighting started and we were locked down. It was this moment of when you see the gunshots so close, you kind of go "hmmm, right.” But that's when the adrenaline comes in. You just mobilize and the moment they called the ceasefire, we were out seeing where the people had run to and how to set up mobile clinics. It's an incredible feeling, and so real and so pertinent in such a setting. 

It's a reflection of where MSF is today. And for those who may or may not know MSF -- Médecins Sans Frontières, Doctors Without Borders, -- we're quite independent as an international medical organization. We were founded in 1971, in the wake of the Biafra war in Nigeria, so we're actually celebrating our 50 years of existence this year. Part of the work that we do is addressing those people who are most vulnerable -- caught in conflicts, epidemics, natural or manmade disasters. We're in over seventy countries with over forty-six thousand members today. We started off with three hundred in 1971. Today, we're a huge workforce with 80% of that local, and that is driven by medical ethics and the humanitarian principles -- especially neutrality, impartiality. 

That independence is critical, because it's independence from any political affiliation, independence from any economic affiliation. We're lucky that today 97% of our funds come from individuals, seven million private donors, because there's something about being able to say to a rebel group, who asks, "Who are you affiliated with?" when we say "No, we are private. We don't have any state affiliations or are part of a political agenda. We are here to do the work that we do.”  That contract with the community is so critical in maintaining our safety and security. 

So, where I am today and my role in those eighteen years of growing up in MSF is trying to actually understand how we can do better…how to be more relevant and more purposeful, and what does the next fifty years look like for us? That's part of the work that I do. It's really how do we drive that voice and be as effective as we can, knowing that emergencies of the future are going to be incredibly complex and compounded and just cascading one upon the other, and you see that today, more and more.

Shiv Gaglani: That's incredible. Thanks for sharing those stories, and then also the size and scope of MSF, which is mind-blowing in fifty years, how much you have grown and how much grassroots support there is for MSF. The last two years have accelerated a lot of trends in healthcare. That's one of the main reasons we launched this podcast, and we keep hearing about how unprepared our public health system in the U.S. has been for COVID, let alone internationally. What is your assessment of the state of global health, particularly in light of the pandemic and your involvement with COVAX? Because I feel like it's kind of gone out of the news. People are tired of COVID. I don't think the answer is that we’re fully prepared for the next pandemic at all, but given your eighteen years dedicated to global health, and public health, what do the next eighteen years look like in your assessment? What do we need to do to be more prepared?

Dr. Maria Guevara: Well, gosh, that's a big question. Before I actually became the International Medical Secretary, I was holding different dossiers. One was a Senior Advisor in Global Health Issues, and before that, I was representing in Asia but also the coordinator for that healthcare portfolio, so very much entrenched in the global health agenda. Global health as a discipline just started really coming in the last decade or so. It's been public health, and international health, but the globalization of the world has made it a reality, and unfortunately, our mechanisms today called “human systems” are failing. Failure of governance, failure of knowledge, failure of imagination.

When we created what they call the multilateral systems like the United Nations they were supposed to maintain international peace and security, achieve international cooperation, to be a center for harmonizing nations. A great concept, right? A noble intention, but unfortunately, it's failing. Why? Many reasons, but I think the rate-limiting step is the willingness of the individual nations to play together, and that tension between nationalism and multilateralism is really some of the core. Some of it is that a lot of these multilateral mechanisms are also beholden to the funding and the support of such nations. When those tensions come face to face, and COVID is very much that, but also, if you were to look at the next global health threat of the century which is climate change -- which is ongoing since before COVID, but probably related to why we are seeing COVID -- it's really highlighting that there are all these issues that are just really complex and it's really hard to tell one nation to prioritize another. There's this kind of sovereignty. So, part of the global health system, or global health or just the global world is challenged because of these inherent tensions. 

What we're seeing is just this incredible structural violence that is coming up in health inequalities, disparities and equities, front and center. There's a lot of lip service to try to work together. There's nothing more amazing than an emergency in driving people together, so there was this hope that COVID is actually is an opportunity. We're getting dress rehearsals on a regular basis to see how we can fix ourselves. It's like, Mother Earth is saying, “We're going to teach you. Learn!” But we're still struggling. 

It's really highlighting the need to have solidarity and to work collectively. What does it mean to do that?What is the concept of equity? In trying to secure health, sometimes we don't have the proper words and framing to do it. Like global health security is failing because we have a different framing of this and understanding. I think the experience from COVAX is the same, right? It is this beautiful intention to try to address this inequity, but it's failing because it's using the same failed human systems to create the act. It's so dependent on nation-states, but it's also dependent on those big, global health foundations that are also dependent on nations and donors and that framing is very market-based. It's really related to our neoliberal, capitalistic drive for this constant economic growth, which is maybe the way we need to rephrase that. 

I've always said the core of our work at MSF is a humanitarian crisis, but sadly, it's about fighting the fallout of this much larger crisis of humanity that we all are facing. We've somehow lost that social fabric of what does it mean to be a community, a human community? I think there's an existential question here that we need to address. Anyways, I can go on, but I'll stop there.

Shiv Gaglani: I think you've nailed it. Even in the U.S. we've had trouble, as you know, bolstering the public health system. In the wake of COVID, it seems like the government has forgotten, and moved on to other crises or other domestic or international issues. It is a challenge. Obviously, there's still a lot of talk around. Bill Gates has written a book most recently about how we can address the next pandemic and develop a surveillance system. So it seems like there are still organizations trying to do this. They're going to be investing a lot more, the Gates Foundation will be, but there are other individuals who are really motivated to make sure this doesn't happen as much. 

So, speaking of what individuals can do, many people in our audience of current and future healthcare professionals want to be volunteers for MSF and other organizations that do good work around the world. What would be ways that they can get involved that you would recommend and then also, what's your advice to them about meeting the challenges of this state of global health and public health affairs?

Dr. Maria Guevara: Sure. I think donating is a no-brainer and I'm grateful for the support that we get, because at least 59% of our work is actually in conflict settings and is super critical. So that's one, but two is understanding our future. Your audience is our future, our volunteers, and we need them to carry the mission of making healthcare accessible to all. But it requires an understanding of not only what it means to provide direct patient care, but really understanding that landscape that you work in. 

Let me tell you about something that I learned in MSF. I was working in a high-end University of Florida hospital, right? Very high level of technical and direct care. But in MSF, you cannot help but have to focus in the community because it's this tension between patient care and public health. And it's so critical today, where the local and global kind of intersects. I think we need to educate ourselves around that and be as broad-minded as possible, looking beyond your own siloed education. 

Then three is a voice. I mean, I think if there's anything that we learned through COVID -- even despite the attacks and mistrust of science -- there's still this belief in doctors and medical workers and the voice that that carries. We need to empower that voice and to be enraged by what we see in our emergency rooms that's linked to all these disasters. It's a powerful voice and we need to amplify that. So, wherever you might be working in your emergency room, your voice is just as powerful and can be a galvanizing force. 

Then lastly, to the question of challenges of today, as a leader in MSF I'm really involved in trying to understand what does it mean to work in a state of well-being, to understand what that means to be more self-conscious of my own self-regulation, and how to stay calm, collected, and be courageous, creative and curious. How do I maintain that? It's really about putting the inner world as a priority. What does that mean for you? Self-regulating yourself, because without that everything stops. So, I take that moment to do self-care -- meditate, yoga, exercise, whatever it is -- that makes you ground yourself. 

It's also critical in this incredibly changing world, in this ecosystem that we live on…this planet earth, to get involved in planetary health and understand your role in that in a very centered way.

Shiv Gaglani: That's great. I think that really will resonate with many of the themes we've heard, and it’s increasingly important, because obviously, one of many negative things that this pandemic has done is accelerated a lot of the moral injury or burnout of the healthcare workforce and made some of the systems that we use to provide healthcare financially untenable. Trying to figure out how to rebuild and strengthen the healthcare workforce is a core priority that keeps coming up on this podcast. 

I'm respectful of your time. You're in Geneva right now, so I know it's getting a little later there. Two other questions if you don't mind. The first is, as you know, Osmosis is a health education company. We care a lot about filling in knowledge gaps. If you could snap your fingers and train this next generation of healthcare professionals on one or two concepts, what would it be?

Dr. Maria Guevara: So, other than medical humanitarian action, the other topic that I'm really passionate about is planetary health. Beyond MSF, I'm pushing different initiatives and working with some very bright people in Asia-Pacific, where I had represented before, and created this initiative on planetary health. We want to integrate it, basically mainstream it in our education system and the university curricula, but especially in medical schools. It's based at Sunway University in Malaysia.

As I mentioned, failures of the human system sits at the core of planetary health. We are part of this ecosystem that we call earth, and the fact that we're experiencing emerging infectious diseases, pollution, massive climate changes, is partly because we are at fault. The IPCC -- which is the Intergovernmental Panel on Climate Change -- publishes these review articles and reports. Their sixth report just came out, and basically, they're saying humans are responsible, and this is an emergency and we need to do something about it. This is affecting the most vulnerable. It's at the core of what MSF does. This kind of knowledge of how do we see ourselves within an ecosystem -- whether that's in a local public health way, or global health way, but within the planetary health realm -- I think we need to educate the future health workforce to understand how we are actually quite connected globally. I would want to encourage this and if you need any kind of collaborations on that, I’m happy to volunteer. 

Shiv Gaglani: Yeah, we’d definitely love to follow up. That's one reason we like to ask the question is, we have this platform and engine for creating content that we'd love to be able to apply to diversity, equity, inclusion content, doing a lot of public health content, but also about planetary health. Our audience tends to skew younger and hopefully will be around for the next few decades when many of these things are going to be staring us right in the face. They already are with the climate. Yesterday we had a guest from London on the podcast, and it was forty degrees Celsius in London…the hottest day in recorded history there. That's not a place that has a lot of air conditioning. That's obviously one of the most developed countries. Is there anything else you wish I'd asked you about that you'd like to get across to our audience?

Dr. Maria Guevara: I guess it's more about understanding who you are…why you, yourself decided to be a health professional.  I think if there's anything I learned through these years, it's this passion to serve. If you know that's who you aren't, you can go wrong.  I think it's following that light within. I just wanted to send that message out, and if we can establish or reinforce these kinds of principles and moral values and ethics within ourselves and propagate this kind of stance and perspective, then we will go a long way in addressing the crisis that we see today.

Shiv Gaglani: That's a very positive note to end on, Dr. Guevara. I really appreciate not only you taking the time to be with us on the podcast, but more importantly for your career and what you've dedicated to improving public and global health at MSF and beyond. 

Dr. Maria Guevara: Thank you, my pleasure. 

Shiv Gaglani: With that, I'm Shiv Gaglani, thank you to our audience for checking out today's show. And remember to do your part to flatten the curve and Raise the Line. We're all in this together. Take care.