Dr. Joanne Liu is the former president of Médecins sans frontières (Doctors Without Borders) and a paediatric emergency medicine physician currently working at Sainte Justine Children’s Hospital in Montreal. With nearly 25 years of experience working for MSF, including on-the-ground experience fighting the Ebola outbreak in West Africa in 2014–2015, Liu is an international expert in fighting epidemics.

In mid-April the CBC reported that the Quebec government had declined Dr. Liu’s offer to assist in planning the province’s COVID-19 response. Instead, the Legault administration wanted her to serve Inuit and Indigenous communities in Northern Quebec — because of her experience in Africa, they said.

An anonymous source quoted by Radio-Canada said the actual reason the government healthcare bureaucracy didn’t accept Dr. Liu’s offer of help was because of fears she could not be controlled.

According to Quebec health minister Danielle McCann, this was all a misunderstanding, and Dr. Liu’s help in long-term care facilities — where most COVID-19 deaths are happening — was welcome.

Ricochet spoke with Dr. Liu at length about how her experience with epidemics informs her understanding of COVID-19, and the challenges and failures of Quebec’s and Canada’s responses: “When an epidemic is sweeping through a country, it will uncover every single weakness in your healthcare system and shine a spotlight on it.”


What are the similarities between Ebola and COVID-19?

Dr. Liu: It’s important to underline that COVID-19 is what I call a medical, economic, social phenomenon, like Ebola in 2014–15 in West Africa or like it was as well in 2018–19 in Kivu, Democratic Republic of Congo. It basically affects everyone in the community at the social, economic and personal levels. In a country like Canada we have never had such a phenomenon. All of a sudden all the layers of society were affected by one particular disease.

“We don’t have the right governance platform to dispatch the resources.”

This is a bit of the legacy of Ebola, that the medical community acted quickly. The sequencing of COVID-19 was shared very early on. People are trying, as much as they can, to be transparent with their data.

How are these epidemics different?

The major dissimilarity is the issue of global stockpiles. Ebola was more circumscribed, so we didn’t have the whole world asking for the same thing). With COVID-19, for the first time the whole world is asking for the same PPE [personal protective equipment] and other medical equipment simultaneously. So how do you manage this demand? It creates shortages. How do you redistribute the goods?

Has the international community responded similarly?

What has been realized is that we don’t have the right governance platform to dispatch the resources, be it medical equipment, protective gear or the human resources.

The other thing that’s quite interesting as well — and that’s quite different — is the degree of disagreement on the implementation of quarantine and travel bans, and how this seems to be our only tool in the toolkit. There was a 180-degree turn on our position concerning isolation, quarantine and travel bans [as politicians went from encouraging travel and leisure to implementing strict control measures].

If we focus primarily on healthcare, what has COVID-19 taught us so far?

Looking at the big picture, it’s the collateral damage: COVID-19 has had a negative impact on non-COVID patients. We need to understand what the total cost is in terms of increased morbidity and mortality after having put our healthcare system on pause. This is going to be a very important thing to look at.

Another key difference between the last Ebola outbreaks and our response to COVID-19 is the impact on vulnerable people, particularly the elderly. This was not on our society’s radar. We were caught off guard. What epidemics do, and this is why I find it fascinating, is how they have no mercy whatsoever on a healthcare system.

When an epidemic is sweeping through a country, it will uncover every single weakness in your healthcare system and shine a spotlight on it. That’s what happened with long-term care facilities. We are really eating our humble pie right now. So for me I like this challenge, even though it creates so much suffering, but I like the fact that it forces us to be humble. The epidemic demands solidarity and humility.

How are we lacking in humility?

We’ve become convinced that since we’re a G7 country we could easily handle the epidemic.

I think the IPC [infection prevention and control] has been a challenge. I’ve been advocating treating COVID-positive patients outside the hospital system, or at least within designated sections of hospitals, and ensuring against swapping the staff. There should be a closed system for patients and hospital workers to prevent cross-contamination. This has been an important challenge.

“I don’t think that human beings are meant to die alone.”

Safeguarding the integrity of our hospital workers — physically and mentally — has been a challenge as well, and I think that we’ve been managing the epidemic largely based on scarcity. We’ve been adapting our policies according to shortages instead of adapting ourselves to the reality. No wonder we are missing at least one thousand trained medical professionals and healthcare workers from our long-term care facilities in Quebec and Ontario.

It’s nice that people call us their guardian angels — but at the end of the day if you want me to keep being your guardian angel, you’re going to need to protect me, and protect me properly. That means I need to feel safe where I’m working, and that means I need the best equipment. But if that’s not possible, I’m a reasonable person. Don’t tell me it’s safe when it isn’t — just tell me we’re running out of stuff.

Are there similarities between Ebola and COVID-19 with regards to vulnerable populations like the elderly?

At a micro level, it would be dying alone. I’ve said it over and over: I don’t think that human beings are meant to die alone. I don’t think human beings are meant to die away from their loved ones. This is an unfortunate similarity with the 2014–15 Ebola outbreak in West Africa: people forced to die alone with other people wearing PPE — I say cosmonaut because to me that’s what they look like [in full-body protective gear]. To me that’s very distressing, it’s not humane. I think this is what people might remember the most, knowing people — their grandmother — died alone in a long-term care facility.

Are our governments acting based on fear? Is it all reactive?

The overall similarity is the human factor, which is to say the fear factor. Widespread fear is never factored in when we do simulations. We assume people will volunteer to help and that we’ll have the necessary numbers of healthcare workers, but we don’t factor in what happens when people are scared for their lives. When people are scared they could call in sick, but they might also do the wrong thing and unintentionally infect themselves. This is why our simulations have limits: human beings are human beings, and human beings are scared.

You mentioned before that there should be dedicated facilities for COVID-19 positive patients. Should they not be treated in hospitals?

I have been advocating for dedicated COVID-19 facilities since the beginning but this was way, way too hard for people to imagine. This would require a different planning approach, one that would assess need by region or sector. We’re just not used to that here. We’re not used to thinking on these levels and we’re not very good at helping each other out.

It’s like we went into prima donna mode, saying “I’m the best, I can do that.” This is how we got to having different zones: hot zones, lukewarm zones, cold zones. This is okay if you can put in place a closed-circuit system for COVID-19 positive patients, but this never happened.

Mixing hospital staff has been a major challenge. If you have a staff handling COVID-19-positive patients, they shouldn’t be treating COVID-19-negative patients elsewhere in the hospital or in long-term care facilities. Even if these healthcare professionals are washing their hands between patients, there’s still the possibility of cross-contamination.

There’s also the problem of asymptomatic COVID-19 positive patients,and this was also a problem in West Africa. If you’re not careful then your healthcare workers become carriers of the virus.

Tell me more about the problem of asymptomatic COVID-19 carriers.

Right now I think it’s clear there are a lot of people who may be asymptomatic and are carriers of the virus, and of course they have no idea. How do we tackle this? Well, it’s hard. Should there be self-monitoring for fever? Yes, at the very least. And this should apply to anyone caring for others.

Safeguarding the integrity of our hospital workers — physically and mentally — has been a challenge.

But the other thing is that when we know of people working with COVID-19-positive patients who are exposed. The ideal would have been to have regularly tested COVID-19-dedicated staff. This also should have been done in the long-term care facilities because you don’t want your staff to be the vector of the virus. Right now there are few long-term care facilities in which all the residents and all the caregivers have been tested. This isn’t as widespread as it needs to be because we just don’t have enough tests.

How can you effectively test for this virus given the scarcity of available materials and the cumulative negative impacts on the healthcare sector that you’ve already mentioned?

We need a testing strategy — we need to establish our testing priorities. I know the Canadian government has provided their guidance, and this is being discussed at a provincial level.

This is what we do with cholera or malaria outbreaks: we begin by testing everybody and then at a certain point, because of community transmission, we assume people with symptoms have the disease. At this point, we can then save tests for something else.

What some other countries have done — and I’m not saying this as either an epidemiologist or as a public health official — but in other countries people who report symptoms are told to self-isolate and then, in Switzerland, as an example, they will order a serology [blood] test instead afterwards, so that they have an exact number [of cases]. [A blood test can determine if a person has ever had COVID-19, whereas other testing methods can only tell if a person currently has the virus.] Doing it this way allows COVID-19-specific testing to be saved for whoever needs to be prioritized.

This is something where we need to reflect very carefully. Who gets prioritized for COVID-19 testing when we just don’t have the capacity to test everyone? Do we need to test everyone who is symptomatic? Do we test everyone who has already self-isolated? Should we prioritize just people admitted to hospital because they present a potential threat to the staff and other patients? Should we test healthcare workers more often? This is an issue that needs to be put on the table and discussed in a much more clear way.

What do you make of the resistance to self-isolation and quarantine, especially in the United States?

I’ll put it this way: we are building the sailboat while we are sailing. We don’t have the evidence that is necessary to comfortably make recommendations. We haven’t ever faced a pandemic where we asked for a widespread lockdown. I remember back in January we were looking at Wuhan and saying, “Oh my god, they locked down a city of 12 million people, there’s no way we can do that in New York, in Montreal.” Well guess what? Maybe we didn’t succeed as best we could have, but we tried and we did it.

Have politicians in North America helped or hindered the response to the pandemic?

What’s destabilizing here is that we’re all learning as we’re going along. I think there are some people who are very assertive in their comments and recommendations instead of being honest and saying “this is what we have so far, this is how much we know and we’re advising based on what we know today and we’re asking you to please comply with that.”

The thing is, it’s really quite hard to keep people’s trust when you’re navigating uncertainties. In the end it boils down to how much charisma, honesty, transparency a leader can bring to maintain the public’s trust.

There’s no question this is hard. I remember when Ellen Sirleaf [president of Liberia during the Ebola crisis] had to do a total lockdown of Monrovia. There was rioting, people were quite upset. So she pulled back from that. Then when she had to incinerate the bodies of the dead [instead of allowing customary mourning], because we couldn’t handle the volume of corpses [and they were still contagious]. She apologized for that.

The day Sirleaf apologized for this, she gained back people’s trust. People could accept that. She was honest with her people and people accepted that. I find it fascinating that our leaders today are incapable of humility when they speak. I think the people would actually be more understanding than politicians would believe. Of course there will always be 10 to 30 per cent of the population who think this is all a plot or a conspiracy theory and we’ll never be able to convince them.

What else do politicians need to consider as they reflect on how they’ve handled this crisis?

For the majority of people you ought to be able to speak to them and share your concerns and hesitations in a calm and convincing way that does not add up to creating fear and ambiguity, but that’s a fine line. In order to do that you need to be a leader with a lot of self-confidence. And I think a lot of our leaders don’t have much self-confidence. I don’t have an issue with telling people when I’ve made a mistake or that I don’t have the answer. I don’t mind saying I need more evidence so that I can analyze a problem better but that I don’t have it now. But a lot of people are not able to do that. They think that they need to be completely assertive or that there will be a backlash if they show some uncertainty.

This interview has been edited for length and clarity.