Joanne Liu, M.D., C.M., FRCPC, International President of Médecins Sans Frontières (MSF)

Dr. Joanne Liu, you have served as International President of Médecins Sans Frontières (MSF) since 2013 and have been involved with the organization since 1996. Could you please explain to our readers about MSF as a global humanitarian organization and how it operates?

Simply put, MSF operates on one core principle: to work in areas that demonstrate need for medical humanitarian help. Many people from all over the world lack access to healthcare for a range of reasons. MSF works to help these populations situated in conflict zones, protected crises, epidemics, natural disasters, and those who are stigmatized and marginalized. In the past, for example, we have provided assistance to women in Afghanistan. Currently, we are working with populations that suffer from neglected tropical diseases or NTDs such as Leishmaniasis. These are the kinds of events we are witnessing.

Could you describe some of the major changes and improvements you have witnessed in the world during your time at MSF?

I think the present issue is that the way in which people wage wars has changed. Civilians are not spared, and we powerlessly witness this in Syria as well as in Yemen. Bombs are being dropped in residential and public spaces, and last year an airstrike hit a school bus in Yemen that killed 40 children. This is quite distressing, if not scandalous.

Moreover, hospitals are not being spared. While I don’t have a benchmark number of hospitals targeted in the past, the reality today is that hospitals are being bombed over and over again and more so than ever. We know that more than 50 percent of the hospitals in Yemen have been partly or fully destroyed due to the ongoing war.

Dr. Liu posing with an Ebola survivor at the Ebola treatment center in Butembo, DR Congo (Photo by: Laurie Bonnaud/MSF)

For MSF, there is one stark event, what I call a black day in our history that occured in Kunduz, a city in northeastern Afghanistan. Back in October 3rd of 2015, the Kunduz Trauma Center operated by our team was bombed by not one, but by five air strikes within the span of an hour and 10 minutes, and 42 people lost their lives. It is one thing when one air strike happens; it is another when five precise air strikes hit the central building of our trauma center. This is what I call a precise mistake. This event alongside the others I’ve mentioned earlier demonstrate a change in the way wars are being waged today.

One of the things we did during my two mandates is that MSF sought after political reaffirmations that hospitals would remain a safe space for both patients and medical staffs, whether in Kunduz, Afghanistan; Sana’a, Yemen; or Montreal, Canada. This was reiterated with the Resolution 2286 on May 3rd, 2016. In reality however, although it was voted unanimously with 80 countries backing up the resolution, the fact remains that the resolution did not change much of this problem. This represents that change in how wars are waged is related to the change in the world’s multilateral platform and brings up the question, “What power do they really have?”

The other thing that has really changed, and I think we need to emphasize, is the criminalization of migrants, or people who are fleeing for their lives. Right now, refugees placed in Libyan migrant detention centers are stripped of their basic human rights. The fact that we are also criminalizing those bringing aid to migrants or refugees crossing the Mediterranean sea, and the fact that saving lives in the Mediterranean sea is illegal - these are things I never thought that I would witness in my life.

“In 2019, we were able to deploy several new tools to fight Ebola, signaling that when we have the political will, we can get things done”

We are all in a very difficult moment in human history, and a moment of uncertainty as a world. However, I believe there are also positive changes, and the evolution of the Ebola crisis is exemplary of some of the improvements. Back when I began my mandate in 2013, the start of the Ebola epidemics in West Africa shortly followed just a few months in. I recall us begging to obtain the needed vaccines and therapeutic solutions to care for the people affected by Ebola. Fast forwarding to last year and this year, we have been able to scale up vaccinations for both the people affected by the disease and the workers on the frontlines in providing care. As a result, we have vaccinated more than 160,000 people. Additionally, we are now conducting trials for four therapeutic solutions in north Kivu of the Democratic Republic of Congo (DRC), which will soon conclude as we are close to reaching over 500 participants in these trials. If we were to have taken the normal rate of discovery in research and development, these improvements would not have come to fruition just few years after the outbreak in West Africa. Yet in 2018 and 2019, we were able to deploy several new tools to fight Ebola, signaling that when we have the political will, we can get things done.

MSF responds to an array of humanitarian crises: wars, natural disasters of any kind, epidemics, pandemics, forcibly displaced refugees, and famines. You have indicated that a lot of the obstacles you faced were political in nature. Are there other obstacles MSF had to encounter in order to reach those in need of medical attention? What are some measures MSF is taking to address them?

If I were to summarize our key challenges in terms of deployment, it is access. There are challenges in MSF’s access to populations in need, the populations’ access to our healthcare facilities, and people’s access to medicine in general.

It is always difficult to access populations when they are in remote areas, where we have to cross several checkpoints just to reach them. In some places, if we do not have the means to airlift our team members, it is unlikely that we will reach these remote populations.

Access is also an issue in terms of populations coming to us for help. We have seen it in Yemen everyday since the beginning of the country’s conflict. MSF, for example, has 2,200 staff in Yemen who are providing direct support to more than a dozen hospitals and another 15 remotely. The reality is, however, that not all people are able to come to our centers, and the reasons include roadblocks as well as their inaccessibility to fuel that will allow them to make the journey to these hospitals. This issue with access is truly devastating: over the past year and a half, there were 600 people who arrived with a slim chance of survival, many being children and newborn. We are not talking about the people wounded from war; we are talking about the general, civilian populations seeking care. A journey that should only take 30 minutes to arrive to a hospital can end up taking hours, if not days, because of these roadblocks, fuel insecurities, and checkpoints.

The last aspect of access is our access to medicine. I think we have seen it in the ongoing HIV/AIDS epidemic where despite the development of new forms of treatment, they remain inaccessible due to their inflated prices. Meaning, even when the right tools are materially available, people who cannot afford it will still die from a treatable condition. This was the big battle in the beginning of the millennium. Fortunately, there is now accessibility to generic medicine for the general population. The cost of antiretroviral treatments (ARVs) went from more than $10,000 to less than $200 within a year’s time, and this was a huge achievement. In essence, access to medicine is a real issue. We have seen it in the U.S. with epinephrine a year and a half ago. This concern as to how we will continue to maintain access to new treatment discoveries at an affordable price is one that pertains to everybody.

As I have stated earlier, even if we may have a medical breakthrough, if people cannot afford it, there is no use. As I always say, if you have a vaccine, it is only useful not in the freezer, but in the arms of the person who needs it. This is what we have been trying to do at MSF, and this is why the Access Campaign that was put together in 1999.

The idea in the message is very clear: if the best available medicine and tests are accessible to those who need them, many more lives would be saved. This was clear to us early on, and this is what MSF tries to promote at all times. If we are to be available as a provider of medical services, we need to see what we can do about the intellectual property

of medicine, where we can treat it as a public good rather than a private one. This was a highly challenging legal fight. I think people today, however, better see the role of generics, and this helps bring accessibility to those who need it the most.

Dr. Liu and medical team at the MSF Trauma Center in Afghanistan (Photo by: Kim Clausen/MSF)

Despite various organizations’ goal and effort to relieve global humanitarian crises, many of them face limited budgetary and human resources. What aspects drive MSF to carry out its mission without facing such issues?

As an organization, we are very fortunate. We are an organization today with an approximately $1.6 billion incoming operational budget and a global workforce of 68,000 headcounts on a yearly basis working in 72 countries. We have the immense privilege to be funded by 6.5 million individual donors and private institutions. This is a real privilege. By having private donors, we have an agenda that is stripped of any political bias from institutional or state donors. This allows us to invest in things that might not always be successful, but can make a difference. For instance, nobody believed in the Access Campaign in 1999. I remember back then, we invested the money that we had received from the Nobel Peace Prize into launching our Access Campaign for medicine. Today, we have invested in the discovery of a new molecule to conduct trials for Hepatitis C treatment. Instead of having a 12-week treatment costing over $60,000, it is projected to be less than $300 soon. Our independence allows us to invest in solutions that, although are still in their infancy and outside the radar of others, can make a huge difference in people’s lives.

"If we are able to harness the best of our diversity, we will be much further in terms of the quality of our response, innovation, and enacted inclusion"

Moreover, MSF brings value as an independent, neutral organization. Because we have the robustness, independence, and the means of reaching remote populations, more than 60 percent of the countries we intervene in are war zones. South Sudan, for example, is a war zone and its population can be difficult to provide medical services to. People cannot use the roads because they are too dangerous. Because MSF is equipped with our own planes, we use them to fly our teams in and out regularly of what would otherwise be a difficult area to reach. If one does not have the financial robustness to do that, they cannot work as freely and as independently as MSF fortunately can.

MSF is a global organization that consists of 24 independent sections worldwide. How do you, as the International President, lead and sustain a sense of cohesion among these sections?

MSF is a movement with 24 sections and more than 48 offices scattered throughout the world. It is a real challenge to keep all MSF members aligned behind a common mission and foster unity with purpose. With that being said, I truly believe that there is a real added value in being a global multipolar organization because it allows us to have a very true approach to the different challenges we face. Because we have the perspectives of different cultures and countries, and eyes from other points of view, I believe this removes some of our blind spots. When reading a situation or making a decision, the outlook from the eyes of someone coming from Africa may be completely different from that of the eyes of a Canadian. There will be different interpretations and there will be different priorities. However, if we are able to harness the best of our diversity, we will be much further in terms of the quality of our response, innovation, and enacted inclusion.

As your term as International President nears its end, you have had the benefit of multiple years of experience and are now in a position to offer advice. What advice would you offer to your successor? What do you envision for the future of MSF?

I will be leaving this position at the beginning of September, and my successor has been identified and elected fairly recently. I would like to wish him good luck. That being said, my advice would be that as we are growing into a bigger, multipolar, and loosely federated organization, it is key that we do not lose track of what is our primary goal and what is our raison d’être (reason of being). Our raison d’être is about the patients. It is about bringing care to the underserved populations in the world, those who are affected by conflicts, natural disasters, epidemics, or stigmatization. In regards to everything we do as MSF, we always need to think of the patient first. Patients are always in the center of decision making. It is very easy for a growing organization to allow its survival as an institution to take over that of the patient and their survival. We should not be blind to that as this can be a real risk. My advice is to put the patients first; keep your eyes on the core social mission of MSF which is, in essence, caring for the people in need in times of crisis.

In terms of what I see for the future, I may loop in something from the beginning of our conversation, which is that we are all working in a world that is changing. We will have to clearly articulate ourselves in a world where those bringing aid to the “unwanted” populations are criminalized. When MSF was conducting search and rescue operations in the Mediterranean, we were attacked. We were made to feel intimidated and we were dragged into court for our activities. How are we to continue to care for people and their lives lawfully in that context? Are we to continue to care for people that are living in areas or zones controlled by opposition groups such as Al-Shabaab or Al Qaeda, whom the government labels as terrorists? Are we to continue to care for these populations knowing that there is a huge narrative about counter-organizations? MSF should strive to deliver a message that a patient is a patient, even a combatant patient.

Dr. Liu voting during a motion session at the 2018 International General Assembly in Barcelona (Photo by: Bueno De Cock/MSF)

As we come to a close, the World Asian Medical Journal, otherwise known as WAMJ is a medical publication that highlights the contributions of various healthcare professionals of Asian heritage. While many Asians pursue medicine in one way or another, relatively fewer are involved in non-profit, humanitarian organizations such as MSF. For readers of the journal who wish to enter this area of healthcare but are unsure as to where and how to start, can you recommend some steps they might take to follow a path resembling yours?

I am not sure if I would strongly advise them to follow my footsteps exactly. That being said, I must be very honest. Being a first-generation born in Canada, which many people call CBC for Canadian-born Chinese, my parents to this day always ask: “When will you be getting a real job?” That is a common experience for many Asians following non-conventional career paths. Although I found my last job to be very tough, I counted my blessings everyday because it is about doing something meaningful. If going into medical humanitarian care is meaningful for you, then I would say go into it. The best way to prepare

yourself is to have something that is exportable and brings value.

In MSF, out of the 68,000 people working within the organization, doctors only represent between 20 to 25 percent. There is a full scope of different professionals, including nurses, logisticians, and administrative staff, who help make humanitarian work possible. If you were to make a difference, you would have to understand that not everyone is meant to work on the forefront of medical crises, such as in Yemen or at the Ebola center in north Kivu of the DRC; and that is okay. That might not be your fit, but you can contribute otherwise. We are always looking for great staff members to help carry on MSF’s mission. If you do not want to be on the very frontlines of MSF’s services but still would like to contribute as a team member, join our telemedicine project. It is the basic tool that brings expertise advice to the bedside of every one of our patients. You can contribute from your living room and be one of MSF’s experts on our telemedicine platform. We have more than 600 experts around the world, and everyday they answer questions to patients who may be in remote areas, such as South Sudan or the DRC.

Dr. Liu visiting the Ebola treatment center in Butembo, DR Conco (Photo by: Alexander Wade/MSF)

For me, being involved in humanitarian work is to help build a better world. The fundamental approach starts with not being indifferent to the crises going on in the world,

and maybe by simply talking about it. In Libyan detention centers, people are being stripped of their basic human rights just because they fled their homes to save their lives

or to look for a better future. The world could be in a better place if everybody addresses such issues and say “this doesn’t make sense”, instead of turning a blind eye. Right

now, we need people who will not denounce matters that are outrageously unfair, non-equitable, and cruelizing, but who will instead bring these issues into light for discourse

and action.

August 5, 2019

Joanne Liu, M.D., C.M., FRCPC

International President, Médecins Sans Frontières (MSF)

Pediatric Emergency Physician, Associate Professor at CHU Sainte-Justine, Université de Montréal

Joanne Liu, M.D., C.M., FRCPC, is a pediatric emergency physician, associate professor at the Université de Montréal(University of Montreal), and the International President of Médecins Sans Frontières (MSF), also known as Doctors Without Borders. Born in Quebec City, Canada, Dr. Liu trained at McGill University School of Medicine, specializing in pediatrics at Montreal's CHU Sainte-Justine Hospital. in 2013, she received the Teasdale-Corti Humanitarian Award from Royal College of Physicians and Surgeons of Canada. Her time with MSF started in 1996, when she worked with Malian refugees in Mauritania. Since then, she has provided support after the tsunami in Indonesia, assisted people affected by the earthquake and cholera epidemic in Haiti, and worked with Somali refugees in Kenya. In MSF, Dr. Liu also helped create the telemedicine project, which connects MSF physicians in 150 remote sites with a pool of more than 300 medical specialists across the globe. She also helped develop one of the first programs offering comprehensive medical care for survivors of sexual violence in Republic of Congo. Dr. Liu has worked in many other conflict zones, including in Palestine, Central African Republic, and Sudan’s Darfur region.