How the Médecins Sans Frontières Journal Inspired a Lifetime of Humanitarian Service: Paul Spiegel

In this episode of “Cancer and Crisis Talks,” Dr. Jemma Arakelyan had the privilege of speaking with Dr. Paul Spiegel, the Director of the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health. Dr. Spiegel’s extensive experience and remarkable contributions to the field of public health have positioned him as a leading expert in addressing the complex challenges facing the global community.

Paul B. Spiegel serves as the Director of the Johns Hopkins Center for Humanitarian Health and holds the title of Distinguished Professor of Practice at Johns Hopkins Bloomberg School of Public Health. He is renowned for his research on the prevention and response to complex humanitarian emergencies. Spiegel’s research interests include the epidemiology of emergencies, global health security, epidemics, refugee and migrant health, communicable diseases, and the development of indicators for monitoring and evaluation.

Jemma Arakelyan is a medical oncologist and Ph.D. candidate at the City University of Hong Kong. Her research focuses on developing new anticancer treatments and understanding the underlying mechanisms of cancer progression. 

In addition to her academic pursuits, she is an active member of several scientific organizations, including the European School of Oncology (ESO), where she served as an ambassador in Armenia from 2020-2022. Dr. Arakelyan is also the president of the Institute of Cancer and Crisis. The Institute is dedicated to promoting awareness and support for cancer patients facing critical situations like war, pandemic, etc.

Jemma Arakelyan: Hello everyone, welcome to Cancer and Crisis Talks on OncoDaily. I’m your host today. I’m Jemma Arakelyan and I’m the CEO of the Institute of Cancer and Crisis.
And today my guest is Dr. Paul Spiegel. Hello, Dr. Spiegel.

Paul Spiegel: Hello, nice to meet you.

Jemma Arakelyan: Dr. Spiegel is a Canadian physician known internationally for his expertise in responding to humanitarian emergencies, especially refugee crisis. He’s the director of the Johns Hopkins Center for Humanitarian Health and a professor at the John Hopkins Bloomberg School of Public Health.

Previously, Dr. Spiegel held positions as deputy director and chief of public health at the United Nations High Commissioner for Refugees, as well as different roles with organizations like the Centers for Disease Control and Prevention and Medicines Amphibian.

He has published many articles on humanitarian health and migration and has served on important commissions and consortium in this very important field. Dr. Spiegel is our absolute honor to have you today. Can you tell us more about your background? And I think everyone is curious what led you to focus on this very challenging type of research.

Paul Spiegel: Sure. Thank you. Thank you, Jemma.
It’s a pleasure to be here. So I’m a Canadian physician epidemiologist and I’ve been working in humanitarian settings for a long time now, now over maybe 30 years.

And the reason I chose this area really is by chance when I was very young, reading in a journal about Médecins Sans Frontières, their creation, what they were doing and why they were the need for a group like MSF.

And even at that stage, I was probably about 16 or so, I decided this is what I’d like to do with my career. And so I went into medicine knowing that this is what I want to do, which I think is relatively rare. Most people just fall upon this and say, oh, this is interesting. And they stumble upon a career in humanitarian health.

Jemma Arakelyan: Very interesting. Thanks a lot for your response. But I’m pretty sure that this journey was not the easy one, right? So tell us more about your major challenges that you faced during your career.

Paul Spiegel: Sure. Well, I would say when I started, there wasn’t a very clear pathway.
So there wasn’t a Centre for Humanitarian Health or similar centre in other schools. And so this was when I was actually I’m here right now visiting in Toronto, Canada. And the pathway that I was told was that I need to be a physician and then go into internal medicine and then go into tropical medicine.

And this yet that was along many, many, many more years of education. And what I did is after my finished medical school and a year or so of residency, I then went into the field with MSF. I was lucky enough to be able to do that.

Then they needed less experience because it was the field was relatively new. And I went into the field working with South Sudanese refugees at Kakuma Refugee Camp. We started that in 1992.

And when I came back to Canada, to Toronto to continue my studies, it was very clear to me that this was not you don’t need a very, you know, an in-depth clinical background, tropical medicine for this. So I ended up continuing, but then I ended up leaving the residency and eventually working in the field more as a physician and in different areas. And then I went to Hopkins to do an MPH and a preventive medicine residency.

And those were the skills that I think were really important beyond having some clinical skills. It was public health. It was thinking about systems and thinking about communities and community involvement, which you don’t traditionally get in the medical school environment.

Jemma Arakelyan: I see. So, Dr. Spiegel, I want to ask a big challenging question, but I’m very curious about your opinion. So back in 2017, you published a highly impactful paper titled The Humanitarian System is Not Just Broke but Broken in the Lancet.

And this paper highlighted the challenges faced due to the Syrian conflict and also the Ebola epidemic at that time. So now, seven years after, do you think the world is in a better place? No. Because we had COVID recently?

Paul Spiegel: No, I don’t. Sadly. Sadly, no. So I published that piece after I was working with UNHCR, the UN High Commissioner for Refugees, for 14 and a half years. And then I left to join Johns Hopkins in Baltimore. And so I published that piece because at that time, I saw there were so many challenges to a system that was not fit for purpose, the humanitarian system, that was very UN international focused, that wasn’t taking into account, you know, communities and national NGOs.

And it was very much, it was just too focused on systems that were developed from outside various countries that were actually being affected by these communities.
But since then, and of course, we couldn’t predict COVID, we couldn’t predict the numbers of populations that have been displaced, the amount of humanitarian emergencies that are occurring, not just in low, but in middle and even high income countries now.

So the situation hasn’t, the system, humanitarian system hasn’t adapted, yet the overall context has worsened over time. So the piece that I wrote so long ago, I think is even more relevant now, which is why we have now developed a commission.
It’s called the Lancet Commission on Health, Conflict and Forced Displacement, where we’re going to be looking into this in much more detail.

Jemma Arakelyan: So I wanted to ask you about this later, but maybe we can elaborate a little bit on this part, because now you’re a co-chair of Lancet Migration and co-director of the Eco Consortium. So what are your current initiatives and projects, if you can elaborate a little bit and tell us more?

Paul Spiegel: Sure. They vary, I think. So a lot of what we’ve been doing in the past while has been focusing on some mixtures from higher end in terms of, let’s say, global aspects of coordination and leadership and the problems with that. So we’ve done some examination of trying to look at large scale outbreaks in humanitarian settings.

You mentioned Ebola and DRC, but there’s been cholera in Yemen, cholera in Nigeria. And we’ve been analyzing the various systems and how responding to large scale epidemics and responding to in humanitarian settings, we have different coordination mechanisms that don’t align.

We have the problem of, because there’s an insufficient capacity, we then have people moving, everyone moves towards the outbreak. And then some of the basic services that exist that need to continue in humanitarian settings do not continue. And therefore, we have worsening of maternal and neonatal health, for example. So we work on those areas.

Then we get even more specific into much more research at the ground level. So the Equal Consortium is a consortium led by the International Rescue Committee, where we work in four different countries, Somalia, Nigeria, DRC, and South Sudan. And there we’re doing much more specific research on maternal and neonatal health.

And then finally, another example of a project we just finished was looking at what is called case area targeted interventions in cholera. So it’s really at the community level, looking at where cholera cases occur, and then working with NGOs, following what they’re doing to see when you have a cholera case, if you can provide education, safe water, better health care to that case.

And then the community around, will you be able to reduce cholera transmission? So it’s a very big field, and we work on numerous different aspects, including, I may say, cancer and other areas that we started to work on when we noted, you know, I would say 20 years ago, the focus was still on infectious diseases and maternal neonatal health, maternal child health.
But mostly in low-income countries in Africa and parts of Asia.

But starting with the Balkans and Kosovo and Iraq and Syria, we needed to change how we responded in cancers and other, you know, more renal dialysis, very expensive diseases. We needed to take those into account that we had ignored previously.

Jemma Arakelyan: Thanks a lot for this great work that you do. Like these projects, I know how complicated they are, but also so much needed. So you mentioned about cancer, but have you ever conducted any research or initiatives that specifically address the unique challenges faced by cancer patients in refugee settings?

Paul Spiegel: Yes, we have, but not enough, of course, and I think much more needs to be done.
But this was still when I was at UNHCR, the High Commissioner for Refugees, where really with the Iraq conflict and the Syrian conflict following that, we at UNHCR needed to take into account people, refugees, who had left Iraq and left Syria and were going to surrounding countries, but many were already on cancer, were receiving cancer treatment.

And then we needed to continue, UNHCR and the hosting governments needed to continue that treatment. And then furthermore, other people who became, who were refugees, eventually developed cancer.

And so we needed to figure out how to address cancer and other, you know, let’s say more complicated and more expensive treatments that we hadn’t dealt with at UNHCR. And this was a difficult and remains difficult from a public health point of view, because you have a large population that has a lot of health needs, but you have a limited budget.

And so how do you, you know, from a public health perspective, you want to provide the best quality care to the largest numbers of people.
But that in theory could say, well, then you can’t treat the very expensive cases. But that’s, of course, not correct either. You need to be able to try to deal with both.

And so we started to just record what sort of cancers there were, what sort of treatment is needed. We then needed to develop standard operating procedures. You know, for example, we needed to make very difficult decisions.

If the cancer was very far gone, if we knew there would be a high mortality, would we concentrate on providing treatment or would we try to help in terms of palliative care and then concentrate on those cancers that had a much better prognosis? We also had, we’re dealing, it was very interesting, but in the Middle East, you know, you have very, you have Lebanon, which is a privatized system with quite expensive health care.

And you had very different protocols for treating cancer than compared to Syria, than compared to Jordan and Egypt. So there was and is a tremendous amount of, I would say, ethical, financial and public health issues that come up in working with cancer amongst refugees.

Jemma Arakelyan: Did you publish anything?

Paul Spiegel: Yes, we published two, at least two articles amongst Syrian refugees in, Syrian and Iraqi refugees in Jordan and Lebanon. I don’t have the specific dates right now, but if you look up spiegel cancer and refugees, you’ll find it. So we published two, perhaps not surprising, you know, breast cancer was still one of the largest, the largest numbers of people proportionally was breast cancer amongst women.

But there were many other types of cancers. And the other aspect that came out is that in many of these countries, for the host populations, there aren’t screening protocols, let’s say, consistent screening programs for a mammogram or cervical cancer or prostate cancer. And so we all know that, you know, addressing and doing screening will be better for the person and then better for the health system because it will be cheaper.

But that’s not done. And so often, and even cancer registries were complicated. So how to get access to refugees for certain medications where there aren’t enough medications, let’s say, first, I remember there was a very expensive one component of the protocol for breast cancer.

And it was problematic because the numbers of refugees increased the amounts of, you know, the medicines that were available to the host, to the citizens, the nationals. So these bring up a myriad of problems that, you know, the international community needs to address.

Jemma Arakelyan: I see. Also, I’m sure you gave some suggestions how to address these issues as well, right?

Paul Spiegel: Some were, for example, looking at some of the key registries and seeing how refugees can be included. You know, what happens often is at the beginning, people think refugees, they won’t be there for a long period of time. But traditionally, unfortunately, refugees stay in a host country for a decade or more.

And so the other aspect was to try to look at screening programs and see how screening programs, both in the country, the host country, but could be also expanded to refugees as well. Another aspect is trying to look at protocols. You know, when people move, the protocols in Syria for certain types of cancer treatment were quite different than in Jordan and were quite different than in Lebanon, for example.

So how to understand the protocols? What does it mean? How to ensure continuity when you have different protocols and different medications? So there are many aspects. And then we did also, this was a very difficult, but we at UNHCR, we did develop something called the Exceptional Care Committee, which meant these were diseases such as cancers, such as renal dialysis, very more expensive cancers that required hospitalization or very expensive treatments.

And we had to develop protocols and criteria to be transparent of how an organization like UNHCR and working with NGOs and other UN agencies could provide care and who we could provide that care to and who we could not.
And you can imagine that would be very ethically challenging when you just have to choose criteria to say who can receive treatment and who cannot and for what reasons, because of limited funding.

Jemma Arakelyan: Funding is always an issue, right? It’s a big issue.

Paul Spiegel: But not the only issue, of course.
I mean, a lot of it is policy. As I mentioned, if we could do screening in all of these countries, we try to avoid doing special programs for refugees that aren’t available to national populations, because that just increases population dynamics and negative dynamics between host populations of refugees.

So it wouldn’t be right, I think, to increase, let’s say, provide mammography for refugees and not for host populations.
So I think there’s a lot that can be done that is more policy related than just finances in some sense.

Jemma Arakelyan: Is there also an issue with human resources?

Paul Spiegel: Definitely. I mean, human resources and so it would be human resources as well as infrastructure for cancer.
I know we’re talking cancer, but also let’s say renal dialysis and others where you’re going to need people that are professionals that are trained. You’re going to need a certain supply of medications that may not exist, tests. And so it is a problem where in many of these countries where there are refugees, there are already insufficient human resources.

And particularly, as we know, many of those tertiary care sort of work will be in capitals or in cities, and many refugees are just across the border into relatively remote areas. And so it’s not just the number of people or experts to deal with this, it’s also where they’re located.

Jemma Arakelyan: We talked about the Lancet Commission a little bit, and I know you are involved in the Lancet Commission for Migration and Health.
Can you tell us what were the main objectives of this commission and what was the impact?

Paul Spiegel: Yeah, we had the Lancet Commission for Open Migration, and then we have something called Lancet Migration, which is a follow up to that. We also now have, as I said, a new one, a new commission that came out in January that I’m going to be, that I am chairing on Lancet Commission on Health, Conflict and Forced Migration. So that’s going to be a new commission.

The Lancet Migration was broader, looking at all types of migration, including economic, forced, conflict, internally displaced persons. This one is going to focus solely on conflict and forced displacement. But in all of these commissions, I think what we find is, what we find is that there either is not enough data or in many situations, and so there isn’t enough evidence at times to be able to make certain decisions.

We also find consistently that there are issues with equity. And so even within populations, so you’ve got refugees or you’ve got internally displaced persons. Within those populations, they’re not homogenous.

You’ve got people who are wealthier, people that, just like in any situation, in any community, where they will have better access to health care than others. And so, you know, within these populations, we need to focus on vulnerable populations. But we also don’t, we should not focus just on the status of someone like a refugee or internally displaced people.

They are within communities, right, within host communities, and many of those host communities have many needs as well. Yet the way the donor community is functioning, often money goes for refugees or IDPs, but insufficiently to look at just everyone in an area who is vulnerable.

And as I mentioned, that can increase tensions between displaced populations and host populations, when mostly the displaced populations are focused upon.

We’ve also, yeah, and in terms of some of the outcomes, for example, some we’ve had successes, some not. I think we brought the Lancet Migration and Health Commission, I think, brought a lot of focus on the importance of migration, but also future, thinking for the future. I mean, we’re talking about climate change, I was just on a call on climate change, and the amount of people, the number of people that are going to be displaced, due to climate change, as we all know, is going to increase significantly.

And so we need to think about and already anticipate where people may be moving to and the effects on health systems. And that’s going to be, you know, large amount of people, large numbers of people moving are going to affect, they will have cancers, they will have other diseases, yet the where they’re moving to in the health systems are likely not adequately prepared.

Jemma Arakelyan: I see. So, ideally, how do you see the future?

Paul Spiegel: Yeah, well, ideally, or, yeah, ideally, versus, let’s say, So, ideally, I think that it would be, it would be a future in where, where migration is accepted as a natural process, and people are going to be moving for a variety of reasons. And therefore, governments and organizations, whether it be UN multilateral donors, communities themselves, need to think about why people are moving and have more of an acceptance in terms of the yes, these people are going to be moving.

Of course, you know, I’m not suggesting that everyone is going to have the option of moving to where they want to move to, because there are many issues related to that.

But I think people, we need to accept that more and more migration, particularly because of climate change, is going to be happening. And then we need to prepare accordingly. And I guess the reality is that we’re seeing increasing populism, we’re seeing increasing anti-migrant, anti-refugee sentiment.

And that’s going to be problematic, because especially when people have no choice to move, whether it be conflict or whether it be their land is no more habitable, is no longer habitable because of climate, there’s no choice, people are going to be moving. And so we need to prepare accordingly.

Jemma Arakelyan: So my last question for today, Dr. Spiegel, what advice would you give to young professionals who are interested in this field and they really want to work in this particular field?

Paul Spiegel: I would say firstly, it’s an incredibly, it’s an incredible field and incredibly rewarding field to work in.
I would say to young professionals, go with NGOs into the field and be with the communities and the people. Don’t start at headquarters or don’t start with big UN agencies. Really spend time with people in the field to understand their needs, their concerns.

Get your hands dirty, spend a lot of time. And then you can see where a career leads. But really get going and go if you can, if it’s feasible, different countries, different contexts to really understand a wide variety of aspects of why people are moving and their needs and the systems that are going to be needed to adapt.

Jemma Arakelyan: Thanks a lot. It was a great message. And once again, it was our absolute pleasure having you today and wishing you all the best.

Paul Spiegel: Thank you, Jemma. I really appreciate the opportunity to speak with you.

Previous episodes of ‘Cancer and Crisis Talks’ with Jemma Arakelyan

Cancer and Crisis Talks with Dr. Nataliia Verovkina
Cancer and Crisis Talks with Dr. Layth Mula-Hussain
Cancer and Crisis Talks with Dr. Nazik Hammad