Dr. Joanne Liu has spent her career on the front lines of catastrophe. The former International President of Médecins Sans Frontières (MSF) and a leading voice in global health, she has grappled with the world’s hardest problems: the 2014–2016 Ebola epidemic, the bombing of hospitals in active war zones, and the weaponization of migration for political gain.

Containing Ebola, she argues, initially proved nearly impossible: the virus was poorly understood in the region, health workers were infected, and fragile health systems unraveled in real time. Preparedness failures—local, regional, and international—turned the largest Ebola outbreak on record into a global alarm. From those lessons, Liu indicts political timidity and the erosion of humanitarian norms, insisting on stronger international coordination, genuine respect for medical neutrality, and far more proactive crisis management to protect the most vulnerable.

Liu is a pediatric emergency physician at CHU Sainte-Justine, a professor at McGill University’s School of Population and Global Health, and director of the Pandemics and Health Emergencies Readiness Lab (PEARL). From 2013 to 2019, she led MSF, where she oversaw responses to Ebola, the systematic targeting of medical facilities, and the global migrant crisis—work she chronicles in L’Ebola, les Bombes et les Migrants. She serves on multiple global health advisory boards and continues to advocate for pandemic preparedness grounded in humanitarian law and informed by her lived experience in the field.

Scott Douglas Jacobsen: As MSF’s former International President, what were some of the biggest challenges you faced during the 2014–2016 Ebola outbreak?

Dr. Joanne Liu: The biggest challenge we faced as an organization was the overwhelming scale of the epidemic. Looking at the history of Ebola outbreaks, let’s take a step back. Ebola is a virus that causes viral hemorrhagic fever.

Ebola hemorrhagic fever has a case fatality rate of approximately 50% to 70%, depending on the outbreak and the healthcare response. In 2014, there were no specific treatments or vaccines. While we could diagnose the disease, there was no rapid test available. The challenge was that this was the largest outbreak in history in terms of the number of cases.

Before the 2014–2016 outbreak, the largest recorded Ebola outbreak had occurred in 2000–2001 in Uganda, with 425 cases and 224 deaths. The 2014–2016 outbreak in West Africa—affecting Guinea, Sierra Leone, and Liberia—resulted in more than 28,000 infections and over 11,000 deaths.

Having collectively experienced COVID-19, we better understand personal protective equipment (PPE) and the importance of infection control in healthcare settings. But back then, we had to scale up these measures dramatically in West Africa.

Working with healthcare facilities without experience managing an Ebola outbreak was one of the toughest challenges. They lacked the experience, training, and infrastructure to handle such a highly contagious and lethal virus. As a result, when the outbreak began, many healthcare workers became infected and died.

We were working under extreme conditions. The biggest challenges were the limited number of healthcare personnel, the constant exposure to death, and the personal risk of infection. Every single day, we were confronted with the brutal reality of the disease’s lethality.

I remember doing ward rounds and seeing six patients who had died. In PPE, we could only stay in the Ebola treatment units (ETUs) for about an hour because of the intense heat and lack of air conditioning. We had to carefully time our medical visits to minimize risk and maximize efficiency.

To put this in perspective, at CHU Sainte-Justine in Montreal, where I work, we see about 90,000 pediatric patients per year. Our emergency department might experience a maximum of six deaths in a typical year. Yet, during the Ebola outbreak, I witnessed many deaths in a single ward visit.

The greatest difficulties were the shortage of trained staff, the constant exposure to death, and the ever-present risk of infection.

Jacobsen: In the past, you have been critical of the international response. What structural changes are necessary to expedite these types of responses to any outbreak like Ebola?

Liu: We criticized the response because the first cases were traced back to late 2013. However, if I am not mistaken, the outbreak was officially declared in March 2014. It was not until August 8, 2014, that the World Health Organization (WHO) declared it a Public Health Emergency of International Concern.

For about five to six months, we struggled to convince people that this outbreak was different. If we had surged our response capacity earlier, we could have made a significant difference in people’s lives. We worked hands-on in the field, but people were overwhelmed, and the large-scale response did not happen readily. It took several months.

What happened afterward was that the world realized—this was quite interesting—how significant a biological threat could be, not just for WHO but for the rest of the world. What does it mean when a biological threat emerges, spreads rapidly, and truly threatens lives?

For the first time, every day on the news for several weeks, people saw healthcare workers in personal protective equipment (PPE), wearing yellow hazmat suits, walking around and caring for patients. It was a striking image. It was very foreign and strange for medical professionals, but it captured public awareness. People suddenly understood, “Oh my God, this is real, and it can happen.”

What was particularly interesting back then was that countries in West Africa were quickly overwhelmed and needed help from the international community. However, the response from wealthier nations was slow. The global north did not get involved until they felt personally threatened.

And when did they feel threatened? It was when two volunteers from Samaritan’s Purse were medically evacuated to the United States at the end of July 2014. Suddenly, we went from indifference to panic—Ebola was knocking at the door of the Americas. It became a real threat, and there was an urgent push to act fast.

Following the outbreak, numerous evaluations of the response, including WHO’s performance, were conducted. One key outcome was the WHO’s decision to establish a dedicated Emergency Department with greater operational capacity to respond swiftly to such crises. That was one of the key legacies of the Ebola outbreak.

However, the bigger legacy that made a difference during COVID-19 was the development of a research and development (R&D) roadmap. This roadmap prioritized field research and identified the types of viruses for which vaccines should be developed. Additionally, a principle was established that scientific knowledge should be shared openly during a global health crisis.

This principle was critical during COVID-19 when the virus’s genomic sequence was shared early in 2020. Sometimes, people fail to connect the dots, but events unfold more smoothly than they might appear. Even though some people felt there were delays in responding to COVID-19, the process was significantly smoother than it would have been without the lessons learned from the Ebola outbreak of 2014–2016.

Jacobsen: When an outbreak hits—Ebola, COVID-19—experience suggests only coordinated action can contain it. From your vantage as a clinician and former MSF president, what are the principal obstacles to turning that imperative into population-level solutions across member states and multilateral institutions? Where do you see the bottlenecks—governance, financing, supply chains, data sharing, or operational surge capacity? And how much do misinformation and disinformation now degrade public trust and slow response compared with earlier crises?

Liu: I think the main impediment to an adequate response, if we were to have another large-scale epidemic that escalates into a pandemic, would likely be leadership—or rather, the political will to take decisive action.

This is a real concern because one of the unfortunate legacies of COVID-19 is the widespread mistrust and distrust in leadership. People increasingly question facts and data, sometimes outright refusing to believe them or assuming they are part of a larger conspiracy.

At the same time, disinformation and misinformation fuel this skepticism, making public health responses even more difficult. We are in a much more difficult position than before COVID-19.

What is particularly disheartening is that despite our scientific advancements—sending robots to Mars and launching satellites around Earth—a significant portion of the population still does not believe in science.

What strikes me the most, and I should have known this, but was naïve at the time, is that after the 2014–2016 Ebola outbreak, I participated in numerous tabletop simulations and crisis response exercises. And you know what? We never imagined a scenario where state leaders would refuse to believe in science and facts.

That is the greatest challenge we face today.

Jacobsen: Now, the Kunduz hospital airstrike. In 2015, there was a U.S. airstrike on an MSF hospital in Kunduz, Afghanistan. MSF called the attack a war crime and demanded an independent investigation. It was widely condemned. What were the key factors or failures that led to this tragedy?

Liu: On October 3, 2015, the Kunduz trauma center was struck by airstrikes five times in the middle of the night. It was unexpected because the hospital was fully functioning, and we had been operating there for over five years. 42 people died, 14 MSF staff died.

We began negotiating our presence in Kunduz between 2008 and 2011, and we officially opened the trauma center in 2011. It was a 110-bed facility with an intensive care unit, an emergency room, three operating theatres, and 100 hospital beds. It was always at full capacity, treating patients with severe injuries.

At the time of the attack, the frontlines were shifting. The hospital was previously located close to the frontline but on the government-controlled side. However, just days before the attack, control of the area shifted to the opposition—the Taliban.

MSF always maintained a strict policy of neutrality, treating patients from all sides of the conflict. Both government forces and opposition fighters received care at the facility. However, this shift in territorial control affected what happened.

One crucial point to remember is that we were always transparent. We communicated regularly with all parties involved in the conflict and shared our exact GPS coordinates multiple times. Everyone knew where we were.

In that area, we were one of the few buildings with lights on in the middle of the night because, as you may know, there was no central electricity. Everyone relied on generators.

It is possible that the hospital’s ending up on opposition-controlled territory played a role in what happened. We will never know for sure. There have been several investigations, and we requested an independent inquiry from the Humanitarian and International Fact-Finding Commission (HIFCC). However, it never happened because the two countries involved—Afghanistan and the United States—did not give their consent.

Jacobsen: How did this change MSF’s approach to operating in conflict zones?

Liu: We conducted our internal investigation at MSF, and our findings were published and publicly available.

One of the most damning aspects of this tragedy, as I detailed in my book, was that once the attack began, we were unable to stop it. We called everyone—we contacted the United Nations, the special forces, the Pentagon—but we could not get the airstrikes to stop.

Afterward, rebuilding trust and dialogue was extremely difficult. You have to understand that 42 people died, including 14 of our colleagues. The entire MSF movement was in mourning, yet we had to continue our work. We had to care for people—not just in Kunduz, but everywhere.

This is why we fought to clarify the rules of engagement and the laws of war. Do we share the same interpretation of these rules? That question led us to support the work on U.N. Security Council Resolution 2286, which reaffirmed international humanitarian law (IHL) and the protection of medical facilities in conflict zones.

More specifically, we strengthened our direct lines of communication—particularly with the U.S. military. We established what we call an emergency contact system, which we symbolically refer to as a “red phone.” If something happens, we have a designated number to escalate the situation to a high-level chain of command immediately.

We thought we had such a system in place before the attack on Kunduz, but it failed. It was not functioning when we needed it most.

Jacobsen: Now, moving on to the migrant crisis. In Western media, we are seeing a significant rise in anti-immigrant and anti-migrant sentiment. This directly affects how governments handle migration crises and their mitigation efforts.

Many people are unaware that migrants have rights. On an international level, what are we seeing regarding migrant crises, both from a security and humanitarian perspective? What issues are they facing consistently? And are there specific challenges that are particularly severe for migrants today?

Liu: When discussing security and migration, one of the key points I emphasize is that if international humanitarian law (IHL) is not upheld, and if wars are fought without limits, then we should not be surprised that civilians flee. If we want to reduce forced migration, then civilians must be protected.

The reality is that today, 120 million people are forcibly displaced worldwide, and about 50% of them are internally displaced persons (IDPs).

Even when people flee due to horrific violence, they often try to stay as close as possible to their homes. They either relocate within their own country or seek refuge in neighbouring countries. 69% of refugees are in neighbouring countries of the places they fled.

And why? Because people want to go back home. No one wants to be a refugee. No one wants to start from scratch in an unfamiliar country, especially in a place where winter temperatures drop to minus 13 degrees. People do not want to be displaced. That is the first thing to understand.

From a security standpoint, we must return to the rules of war—the fundamental principles of protecting civilians. Civilian infrastructure, such as hospitals, schools, and markets, should not be considered legitimate targets unless proven otherwise. If we continue pursuing wars without limits, then we will inevitably see displacement without limits.

On the humanitarian side, forced displacement is happening everywhere. While the numbers are reaching record highs, displacement is not new. People have been moving throughout history due to adversity, conflict, and survival challenges.
Humans are inherently survivors. They will go where they believe they have a better chance of survival—for themselves, their families, and their children. Right now, 120 million people are in forced displacement, and they require humanitarian aid. Yet, funding for these displaced populations is extremely difficult to secure.

Take Sudan, for example. A war has been raging for over a year, yet it barely makes headlines. Twelve million people have been forcibly displaced in Sudan, but it is rarely discussed in the media. Why? Because media coverage is monopolized by a few conflicts—often those that directly affect the global north.

Jacobsen: The conditions in migrant and refugee camps are often dire. They rarely meet basic living standards. You have raised concerns about this before. What are some of the worst conditions you have witnessed?

Liu: It depends. There are refugee camps, but there are also internally displaced persons (IDP) camps. The reality is that there are more IDPs than refugees in formal camps. Right now, Sudan is breaking records for failing to uphold even the most basic standards of human dignity in its IDP camps.

The Gaza Strip is another example. The conditions there are devastating. We have seen unbearable, unsustainable images that speak for themselves. These are some of the worst examples of displacement crises today.

What was particularly striking in terms of refugee camps—and what shocked people—was what happened in the global north in places like Greece, Italy, and the Balkans during and after the start of the Syrian war. Millions of people were forced to flee.

Of course, when comparing those camps to refugee camps in the Democratic Republic of the Congo (DRC) or Ethiopia, the conditions are different. But what was truly surprising was seeing such dire conditions in wealthy nations—places that should have had the means to provide security, food, and necessities yet failed to do so. That was what I found particularly shocking.

I remember visiting a refugee camp in Greece, and a woman told me they could not go to the bathroom at night without facing the threat of sexual and gender-based violence. It was horrifying.

Jacobsen: What has changed for the better regarding global policy and law regarding migrants? And what remains inadequate or insufficient for the needs of over 100 million displaced people?

Liu: I don’t know much has improved in global migration policy. I had some hope in 2018 when the Global Compact for Migration was adopted in Marrakech. That agreement recognized that migration is inevitable and should be safe, orderly, and regulated. It was meant to establish a framework for making migration as safe as possible for those forced to flee.

But in reality, it was one of those “kumbaya” moments—a symbolic agreement that was not meaningfully implemented. Right now, I am deeply concerned about migration and the well-being of migrants worldwide—including here in Canada. Listening to political leaders, you hear migrants portrayed as the cause of all societal problems.

They are blamed for housing shortages, strained healthcare systems, and, in Quebec, the perceived decline of French language proficiency. This rhetoric extends to claims that migrants threaten the identity of Quebec’s citizens.

Framing migrants as a threat is absurd, especially when you understand that these are people fleeing for their lives. As a humanitarian worker, I find this mindset deeply troubling. And I acknowledge my bias—I always disclose it upfront. I am a product of migration.

Jacobsen: What is Canada doing right and wrong regarding migrants and humanitarian work? How does Canada measure up if we use international law and universal human rights as benchmarks for comparison?

Liu: Well, you just said it. If we were to politically reinforce the application of international humanitarian law (IHL) and universal human rights and truly follow the Global Compact for Migration—which we are a signatory to—then we would be in a much better position.

It is not as if the tools do not exist. They are there. The issue is implementation. Instead of applying them consistently, we choose when to use them based on political convenience.

Jacobsen: What other ways are migrants used as a form of political currency? Beyond the fear-mongering you mentioned earlier—where migrants are framed as a burden or a threat to local culture—how else do political leaders exploit migration for their agendas? The reality is that most migrants are simply trying to survive. More often than not, they are barely surviving.

Liu: For me, migrants have become a scapegoat. They are a convenient way to divert attention from our real challenges, which makes the situation even harder.

Building public support for migration is challenging when many Canadians feel uncertain about their own futures. And they are right—these are uncertain times.

When people feel economically and socially insecure, being open-minded, welcoming, and optimistic can be challenging. Suppose they do not feel confident that they can provide the basics for themselves and their loved ones. How can they be expected to extend that support to others?

That is human nature, and I do not blame people for feeling that way. People want security. If they feel they cannot provide for themselves, they will be reluctant to help others.

As humanitarians and leaders, we must listen to those concerns and find the right balance. But instead, migrants are being used as political currency—a convenient scapegoat for the broader challenges we face.

Jacobsen: Dr. Liu, thank you very much for your time today. I appreciate it.

Liu: Thank you very much.