Joanne Liu, MSF International President: a need for greater humanity
Venue: The Lancet

www.thelancet.com Vol 388 August 27, 2016 861 Medecins Sans Frontieres (MSF) has won high praise for alerting the world to Ebola and responding so fast, but, says Joanne Liu, its International President, for MSF Ebola was a failure: "It took us 6 months to convince the world that something was happening. So for us it was such a trauma." Three issues are of huge concern to her, Liu says, and they are linked. The world ignored Ebola until it was too big to miss and spilling onto rich countries' doorsteps, as international aid workers became infected. Behind that was fear and a lack of understanding of our common humanity. You could say the same for the refugee and migrant crisis. "When Europe started to pay attention is when people started to rattle at the door of Europe" she says. "Then when people started to wash up on beaches. This is when we started to get attention." And that failure to take account of human need, she says, contributes also to the attacks on medical missions like the MSF trauma centre in Kunduz,  "If we are to look at the world only through the lens of our national security interests, if we all continue to do that then we are still going to be late to respond to the next Ebola epidemic, we are still going to continue to have hospitals bombed, and we are still going to have people dying in the Mediterranean sea." Liu, a paediatrician from Quebec City in Canada, trained at the McGill University Faculty of Medicine where she later obtained an international master's in health leadership, and is an associate professor at the Universite de Montreal. She has a high profi le role at MSF, where she started working in 1996. Ebola has been a game changer, she says, leading to a "marriage of convenience" between health and security. That can lead to rich countries taking notice sooner of crises in poor countries but, she says, "if there is an epidemic I want the trigger for response to not be when your national domestic health security is threatened, but a response to medical needs" An international health emergency is declared because a country has not been given help soon enough to avert it. Reform of the way the world responds to epidemics is underway but there are already signs that lessons have not been learned. "We had the acid test with yellow fever and we failed" she says. "By contrast to Ebola we have a vaccine that is working, so we are ahead of the game in so many regards. But the fi rst case happened in December, 2015. I just fi nd it astonishing that we have medicine, we have a vaccine that works, and 6 months down the road we are still not able to contain it. It is still spreading to other countries. It is still spreading within countries." For Liu, Ebola also pointed up "the failed model of R&D" The virus was identifi ed in 1976, but there was no specifi c treatment, diagnostic test, or vaccine. "Over the last few decades R&D has failed to save lives. It is not fi t for purpose. We do things downstream, we do things after things happen" she says. Liu is not against research and development at all. "I truly believe that we need to change the model and I think that we can manage to do that. For me that is the legacy and it's why I'm very happy to see the R&D blueprint that WHO is championing with other actors because that's one of the best ways to prepare ourselves for the next biothreat." The need to engage with clinical trials during the epidemic was tough for MSF, Liu admits. There were fi erce internal arguments about collaborating with scientists and pharmaceutical companies. "MSF is a good responder, is a pretty good doer, is a very bad partner," she says. It's a joke, but there is truth in it. "We have to improve. We're not the easiest organisation to partner with, but we managed to do a few things. But for us there was a big learning curve" she says. Now, though, she is committed to changing the R&D model, "because you don't know what it is to accompany 50% of the people you carry into an Ebola centre and you know they are going to die while you hold their hands and you have nothing to off er except rehydration and some comfort" None of the local staff who bore the brunt of care want to go through that again. Kunduz was another watershed for MSF. The hospital, which was doing remarkable work in trauma care, was bombed on Oct 3, 2015, by a US airforce gunship, killing 42 of the patients and staff The US military originally said the strike was to defend its ground forces. Later US President Barack Obama apologised. "There is always brutality in war and we are not naive" says Liu, but the bombing of Kunduz hospital was not an isolated incident. MSF embarked on a political battle for protection of all those delivering health care to populations affl icted by war. In May, 2016, the UN Security Council passed a resolution condemning attacks on medical missions. That was a start, says Liu, but MSF will keep up the pressure: "We think the UN Security Council is not an end but a beginning of a story on how to halt the attacks on the medical mission." The refugee and migrant crisis, she believes, "will be in our history a very big black mark against humanity because it is dividing us" People uproot their families and fl ee because life is not possible, she says. "Otherwise you would never do that to your children." Health deteriorates as people are deprived of shelter, water, food, and in the reception centres, of something worse. "They say if I knew I would have lost all my dignity by coming here I would have rather died under the bomb in Syria. You hear that over and over again. Part of medicine for me, it's about this word dignity," she says.