Alex Gasasira

Dr. Alex Gasasira

Q: Hello, this is Sam Robson of CDC [United States Centers for Disease Control and Prevention] Museum, here today talking with Dr. Alex Gasasira, WHO [World Health Organization] representative to Liberia. We're talking about his role in the Ebola response in this country, 2014 to 2016, or 2015--

Yeah, we had a few flares up to 2016.

Q: Up to 2016, right. I'm very happy to have you here talking with me today, so thank you very much for that.

GASASIRA: Thank you very much, it's a pleasure.

Q: If I could first ask, would you mind pronouncing for me your full name?

GASASIRA: Okay, my full name, I'm Alex Gasasira. In fact, you pronounced it very well. It's usually not a very easy name for people not from Uganda. I'm from Uganda, I'm a physician. I grew up in Uganda, I went to school in Uganda, I did all my school up to university and medical school in Uganda. I did my 00:01:00post-graduate degree in public health in the UK [United Kingdom], in the University of Leeds in the UK.

Q: Thank you. If you were to give someone just a three sentence maybe, two-to-three sentence description of what your role was in the Ebola response, what would you tell them?

GASASIRA: I coordinated the WHO technical support within Liberia. WHO deployed a lot of people from all over the world, WHO offices all over the world, to Liberia. Once they got into Liberia, my role was to ensure that they contributed the best they could to the overall response, fit in with everybody else that was supporting the response. That was largely my role, especially at the start of 00:02:00the outbreak.

Q: Thank you. I'm going to rewind drastically for a second--can I ask when and where you were born?

GASASIRA: I was born in a little town on the western part of Uganda called Fort Portal almost fifty years ago. To be specific, in May, I will be forty-nine, so forty-nine years ago. I grew up in many parts of Uganda.

Q: Can you tell me a bit about your household? Who you grew up with?

GASASIRA: I was born in a household that was my father--my late father, my mom, and I have one elder brother, and I'm the second in that home, but soon after, there were five others after me. So I have quite a big family, [laughs] the usual African, Ugandan family. We grew up, our father worked in different parts 00:03:00of Uganda. He was an administrator, a civil servant, working in the administrative set-up of Uganda. He was transferred to different districts, and we moved to different parts of the country.

Q: Did you go to secondary school in one place, or were you still moving?

GASASIRA: When I was in my late primary, I moved to a boarding school. That boarding school was run by a religious group, a Catholic group, and they had a secondary school, so all my brothers and I went to the boy's school, went to that school. It was in one part of the country, yes.

Q: What kinds of things were you interested in leading up to going to university?

GASASIRA: I was very interested in history, and I actually wanted, at one point, 00:04:00to become a historian. But in Uganda at that time, growing up, the country was going through tough times. There was a lot of political upheaval. Jobs were tough to get, and the economy was bad. Parents, at that time, always wanted their children to do jobs where they could be self-employed. Traditionally, when I was growing up, parents always encourage their children to either become engineers, to become doctors, or to become lawyers because they could start up their own clinics or law firms. The same happened to us in our family, so our parents were fairly, although--it's a bit [unclear] our parents. Our parents pushed us in that direction, and that's how I ended up moving towards the 00:05:00sciences and then towards the medical field.

Q: Did you feel you had an affinity for those subjects?

GASASIRA: Well, I didn't mind. As I progressed in my secondary school, I realized that I could--I was fairly good at all areas, but I didn't mind doing--in fact, my first choice as I grew up, as I finished my [unclear], I wanted to do engineering. I went to see my late dad, and I told him, and he said, "No, I think you should consider medicine." And I just changed. I didn't really mind. [laughs] As I got into medical school, I realized it was a good choice. I loved what I was doing, and I loved medical school, and I love my work up to now.

Q: What did you love about medical school?

GASASIRA: I liked the fact that you could serve people, you could actually go 00:06:00and see people in distress and try to help them. It was so nice to be able to be of service. I'm sure this happens all over the world, but again, in a country like Uganda, when I was in medical school, that was the height of the HIV/AIDS [human immunodeficiency virus/acquired immune deficiency syndrome] epidemic in our country and there was so much suffering. At that time, unlike now, having an HIV/AIDS diagnosis was like a death sentence. The ability to try to comfort and give the best you could and help people who had this terrible disease, it was really something that I found worthwhile. I liked it. Of course, I loved being able to offer care for curable conditions where you could celebrate at the end of the day, but I felt I was doing something worthwhile.

Q: What did you do after medical school?

GASASIRA: I worked initially in one district hospital, but I soon got a position in our major hospital, the main tertiary hospital, in the accident and emergency department. I did that for a couple of years, and then I got a side job working in a research center where we did a lot of HIV/AIDS research. I did that again for a couple of years before going to the UK to do my master's. Then when I came back, I actually had an opportunity to come to Liberia, as a young doctor, to work on supporting the HIV/AIDS control program. This was immediately after the civil war. I came here for a year and worked here for a year. Lo and behold, CDC 00:08:00at that time was working very closely with WHO on immunization, polio eradication especially, and Liberia was one of the last countries in Africa to start polio eradication. Somebody came in from CDC. I had finished my year's assignment, I was on my way back to Uganda, my bags were packed, and I had said bye to friends, I had farewell parties, and we started talking, and he told me about the work that he was doing. I explained to him what I had done in HIV. My role here was to help strengthen their surveillance network for HIV/AIDS and sexually transmitted infections. That surveillance was a big part of the polio eradication effort. One thing led to another, and he enticed me to consider staying on a little longer. So I did stay on, and I was offered another position 00:09:00with polio eradication. In the end, I stayed in Liberia for five years.

Q: When were those years?

GASASIRA: That was 1997 to 2002. And then I joined the mainstream WHO, and I worked in different countries--from Liberia I went to Zimbabwe. I worked in Zimbabwe for four years at the regional office, and at that time I made several trips to Atlanta to train volunteers who were being deployed to our region, to Africa, to support polio eradication. Then after Zimbabwe, I went to Nigeria--I was the team leader for polio eradication in Nigeria. Again, that was a very, very, very exciting time. That was the time that Nigeria had the worst polio outbreaks in the world, and we worked very, very hard with very good people from, again, all over the world--CDC, UNICEF [United Nations Children's Fund], 00:10:00NGOs [nongovernmental organizations], the government of Nigeria, the traditional leaders, the religious leaders. I spent almost seven and a half years in Nigeria.

After that, I went to the regional office in Brazzaville, our WHO Regional Office, as the polio coordinator for the WHO Africa Region, and that's where I was working--I had just been there a year when Ebola here went out of hand. WHO was mobilizing people from different offices, people who had experience that could be valuable in the Ebola outbreak. Though I had never actually been involved in Ebola directly, which is surprising because I'm from Uganda and everybody thinks that I must have worked on some of the Ebola outbreaks in 00:11:00Uganda, I hadn't. But because, I believe maybe, because I knew Liberia before, I had spent five years here, and then because I had been working in polio eradication and we had done a lot of complex operations and logistics, especially when I was in Nigeria, I think those two factors may have been taken into account when I was deployed to Liberia as the Ebola technical coordinator for WHO. I arrived in Liberia for a six-week mission on the 31st of July, 2014. That was when Ebola was really, really raging. It had recently spread into Monrovia, spread into some of the highly populated slums of Monrovia. It was really, really spreading very rapidly, and the country had not yet gotten the 00:12:00capacity to respond. That is when I arrived in Liberia.

Q: For your six-week mission? [laughter]

GASASIRA: For my six-week mission. Two and a half years down the road, I'm still here.

Q: Wow.

GASASIRA: Yeah. At that time, again, everybody was trying to mobilize. I remember I was fresh off the plane and had to go to attend an Ebola Task Force meeting, which was being chaired by Her Excellency, the President. In the room were senior officials of government, the diplomatic corps, international organizations, but also community members--women, leaders, market leaders, 00:13:00religious leaders. It was in the realm of close to two hundred people, and it was quite impressive to see such a huge number of people from all walks of life. Again, talking and discussing the key issues of how to defeat Ebola. That was my first experience with what was happening in the country, and I was quite impressed by how the government was involving everybody in the decision-making process. It was a big group of people, and some of the issues were very contentious.

I remember that first meeting, one of the things that they were talking about was whether Liberia could adopt cremation because they couldn't bury--the capacity to bury all the dead bodies that were coming about by the high death rates was impossible. A lot of bodies were remaining in communities or left 00:14:00unburied, so it was a discussion about whether cremation could be considered. It was a very tough discussion, very, very tough. On the one hand, there was a group of people with strong cultural attachment who say it has never been their culture to do cremation and there should not be any cremation, even considered. Then there were others who I would say were more pragmatic, would say, look, dead bodies of Ebola victims are a source of infection, we don't have the capacity to bury, we don't have the land, we need to do cremation. It was a very tough meeting. That was my first exposure to--and I remember that as a very, very tough meeting. I was full of admiration--although it was a very scary time--I was full of admiration for how Her Excellency, the President, listened 00:15:00very respectfully to everybody who had a contribution to make. Then, very gracefully, brought the meeting to an end and said that she listened to everybody and they were going to look at this, she was going to make a decision and communicate to everybody. As you may know, she ultimately decided that Liberia should adopt cremation as an emergency action.

Q: What were your own thoughts on the subject?

GASASIRA: My own thoughts on the subject, to be frank, I also come from a society where cremation is not so common, but we were in a desperate situation. Everything had to be done to bring the outbreak under control. At that time, to 00:16:00be absolutely honest, I was pro-cremation because if it could reduce the number of bodies accumulating in the community--at that time, dead bodies were staying in the community for two to three days, and you can imagine how much subsequent transmission was being promoted by these bodies. It was a very tough decision to make, very, very tough, and again, the Liberian government should really be commended for taking these tough and courageous decisions. But those decisions really contributed to bringing the outbreak under control, at the time it happened. If that decision was not taken at that time, I have absolutely no doubt that many, many more people would have been infected and would have died.

Q: Thank you. So you go to this meeting that was about cremation--what else are you working on at this time?

GASASIRA: At that time, Liberia had just put together a national response strategy and plan and was costing it. My main task was to ensure that WHO did its part to support the government and all the other key actors to effectively implement this plan. That plan, however, I must admit, was quickly overtaken by events, because at the time the plan was put together, I think there were just a couple of cases in Monrovia. The number of new cases--the spread and transmission was growing exponentially, so even what was in the plan was soon overtaken by events. A new scale of thinking--within a few days of my arrival, maybe a week, we had to start thinking much bigger than what was in the plan. 00:18:00Again, that plan was overtaken by events and we had to start thinking--our thinking scale had to change dramatically.

At that time, for example, that's the time we started thinking about, if we cannot take everybody into an isolation center--because we just did not have enough beds, and while there was an effort to scale up the number of isolation beds in the Ebola treatment units, building those units, even if we're using temporary building materials that were much faster to do than concrete and mortar, it would still take several weeks to stand up a facility with fifty beds or one hundred beds. We were really racing against time. We realized we were not 00:19:00going to make it. Is there any way we could safely support communities to care for infected people at home? This was completely out-of-the-box thinking--nobody had ever thought that you can even think that. The conventional wisdom was get them out of their home at the first sign of infection, but we couldn't. We were completely overwhelmed. I remember sitting with colleagues from MSF [Medecins Sans Frontieres], from CDC, from USAID [United States Agency for International Development], OFDA [Office of US Foreign Disaster Assistance], and from the Ministry [of Health and Social Welfare] and thinking, is this a feasible option? And also UNICEF. We sat down and we drew on white boards, and we thought out-of-the-box, and it was really, really, very tough. But again, sitting 00:20:00together, working from first principles, we came up with a design that we thought could work and we agreed on where to start this, in the most affected parts of Monrovia and some of the counties out of Monrovia. We started, and the good thing is that we would start, we would evaluate, sometimes we'd think that we have gone wrong, we'd redo things, we'd come back and sit. It was really tough. We knew that we were working against time, we knew that hundreds of families and thousands of people were at risk, and every day that we didn't implement some of these innovative strategies, people would get infected and die. Many of us were not getting more than two to three hours of sleep every night, and would think and would always, again, also worry. Because we wanted to 00:21:00ensure that new people didn't get infected, but we wanted to make sure that all the caregivers, whether they were formal health workers or volunteers from the community, we were not putting anybody at risk. It was very tough, very, very tough, decision-making and discussions that we had. That went on for a couple of weeks.

Q: Were there certain organizations or people who kind of represented both sides of the argument, or either side?

GASASIRA: I think, initially, initially I must say publicly--and I don't know whether--there were some organizations which publicly took a stand and said look, our organization's view is that we can't risk, we can't take any--some of 00:22:00these innovations that you are thinking about are too risky. And that's their public opinion, and in the formal meetings they would tell us, we do not agree that you can think about this.

Q: Who are they?

GASASIRA: I hope I don't get into trouble.

Q: Oh, it's okay if it was a public statement, I assume that--

GASASIRA: But, privately, privately, they give us the best--I mean, they say look, we are thinking outside the box. One thing I really, I got to know and admire so many dedicated professional people because privately they would say okay, we believe in the ETU and these are the principles, but we understand what you are trying to do, and let us sit down and think. Privately, they would help 00:23:00us think through possible solutions and innovations. It was really great. We really worked as a team, and some of these guys had the best experience amongst all of us. Many of us were working from the principles that we knew about it, but we may not have had as much experience, firsthand experience, with Ebola like some of our colleagues from MSF. These colleagues did really--would sit down, draw, go out into the field and do things that were innovative just to save other people's lives. That was one of the most--one of the things that I saw at the height of the outbreak. In a non-crisis situation, there's always a little bit of competition between organizations. People want to get credit, 00:24:00people want to be the first to do things; I was so amazed that during Ebola, this all disappeared. We were all working for the same goal, and there was no CDC, WHO, UNICEF, MSF. We get there, we are sharing ideas, doing the best we can to support the country to do it--and all of us were learning as we went along. Another thing that I would like to say that really facilitated this openness is also the openness of the government. The government allowed the conversation to happen in an open space. Because the conversation was happening openly and 00:25:00honestly and frankly, and people admitting where they had limitations in an open way, this built trust. People trusted each other, and that was key. Actually, we worked as one team, really. It was great. I remember, we all were frightened, we were all frightened that we could even be exposed to undue risks, but everybody did the best they could. I remember initially, as I said, I came for six weeks. The idea was after six weeks you rotate out, but for some organizations like--and some specific positions like the one I held, I couldn't rotate out 00:26:00after six weeks. I stayed another six weeks, and then I stayed much longer. But you'd get so comfortable with colleagues during the six weeks that they were here and they would feel so bad to leave, but some of the organizations it was strict, six weeks and you're out to reduce your risk. As soon as they get out, they are trying to come back in. [laughs] It was really, really remarkable. In my previous life, when I was working in polio in Nigeria, we had a lot of challenges and we had that sort of common teamwork. I used to think that that was wonderful, but in Ebola it was even better.

Q: Was there one specific individual that you can remember who knew that he or she had to leave, but was so eager to come back?

GASASIRA: A lot of the CDC guys, because for CDC it was strict, six weeks, and 00:27:00as soon as they finished five weeks, they become a bit depressed that they have to leave because they get into a kind of mode, and they work, and you really--it's no exaggeration to say that we became one team. It was one team exactly. Everybody was working in a very great, great way.

I remember, again--the real, real tough times were August to September, but towards the end of September, we started getting a lot of foreign medical teams from very many countries and working together. One of the most impressive parts of the whole response operations were the daily incident management system 00:28:00meetings, chaired by Honorable Nyenswah, Tolbert [G.] Nyenswah. I remember at one time, we had almost--we had the US Army in the room, and there was a general, I remember General [Gary J.] Volesky sitting next to Tolbert. There was the China Army in the room, there was the German Army in the room, the head of the African Union response was a general from Uganda representing the AU [African Union]. We had all these generals, and we had this civilian leading and listening and coordinating the meeting and then giving the generals orders, we need support to go to Sinoe [County], we need support to go to Lofa [County], 00:29:00from you, we need this, we need this, and all of them were saying yes sir, yes sir. All of us--I remember thinking to myself, this is really a very--the whole world came together under the leadership of the Liberian government. This really was a factor that led to the success. It was a devastating situation, but it could have gone on much longer. It could have gone on much longer if there was no one sense of purpose, one vision, and everybody coming in to see how do we fit in and contribute the best we could. That worked like clockwork, especially towards the end of 2014, and by December 2014, January 2015, it was like clockwork.

Q: I'm wondering if you could take a minute and just describe Honorable Tolbert 00:30:00Nyenswah a bit. How he is as a person.

GASASIRA: Tolbert Nyenswah, he has many skills. He is an excellent communicator. He is very articulate. He is an excellent listener, but he is a strong guy. Once he listens, he gets everybody's opinion, he facilitates their discussion, and then he says, we are going in this direction. Everybody falls in line and you have to go. And of course, sometimes there were discussions, some people would feel no, no, no, you're making--so he would listen, but at the end, he says, this is the decision. We are all in this together, we have discussed, we have come to this position, and we are moving in this direction. And he stuck to it. The other thing that I really, really admired with him is that once we take 00:31:00decisions, there was follow-up. People had to follow up, people were held accountable. If he says, WHO, you're going to do A, B and C; CDC, you do this; Ministry of Health will do this; the Liberian National Police, you're going to do this; these were all captured, and the next day you had to report. If you didn't do your bit, big trouble. [laughter] Big trouble. He's a very, very strong leader. But if one was to ask me, what do you think is his biggest attribute? He listens and he communicates. Many times after our meetings, he would go to the national radio and tell the country what was going on. That was another thing that I found very, very good because people--of course there were 00:32:00rumors and all kinds of--everybody was scared, frightened, and in such a situation there's always room for falsehoods to emerge, but keeping the country informed. And both Honorable Nyenswah--but all the leaders of the Liberian government, up to Her Excellency, the President. When they made mistakes--and that's another thing I found really remarkable--when they made mistakes, they came back and said we are very sorry, we made a mistake.

Q: Do you have an example of one of them?

GASASIRA: Yes. There was a time that things--there was a part in Monrovia, a slum called West Point, and when many cases started going out of--the number of cases there became very many, they decided to quarantine it off. And there was a place in Margibi County called Dolo Town. These were the two areas that they 00:33:00decided to do a quarantine. To enforce the quarantine, they deployed soldiers, and unfortunately in West Point, the population was breaking out of quarantine and was trying to run out, and the soldiers, unfortunately, shot and one guy was actually killed. After this, Her Excellency the President came out and said look, this was a decision that we shouldn't have taken; we made a mistake, we apologize to the Liberian people. I really found that to be quite, quite, quite remarkable. That's one instance that I remember, that they went on air and publicly said look, sorry, this should not have happened. We apologize. We take responsibility and we'll do it better next time. After those two incidents--that 00:34:00was in, I think, August/September 2014--there was no quarantine in Liberia again. Those are some of the specific incidents I remember.

Q: What was your own part in that discussion about quarantine?

GASASIRA: Most of the international organizations did not agree with quarantine, we sort of anticipated that this is what's going to happen. We should do our part in helping, and this eventually happened, the community should be part of the response, they should be at the heart of the response. We should not be responding on behalf of the community. Ultimately, that's what really happened. The community went ahead and owned their response, and as soon as that was done--but again, we have to remember that when the community really had 00:35:00confidence in the response was when the response also had the capacity to implement what was right. If we said, let the infected people come out, we needed to have the beds or we needed to have where we were going to put them. If we're telling them, don't expose yourself to dead bodies, and they call and say, I have a dead body here, and we couldn't come and pick up that dead body--again, the community had to trust the system. And for the system to deliver, the system had to have that capacity. It was like a chicken-and-egg situation. But as this capacity started getting built and the community said okay, this is something that we can see that there's effort on all sides, then it started falling into place. I told you for example about the challenge about cremation. Initially, in 00:36:00fact, people would die and their community didn't want to report because they say, they are going to cremate. But when they saw that, actually, when the bodies are taken out, fewer people become infected, reluctantly, they also realized that this is the right thing to do. They would call. At that time, there was capacity. The response teams would come, take away the bodies, do their disinfection, go and do the cremation, and then the secondary number of cases started going down. The community realized, actually, if we do this right, we'll protect ourselves. We, again, went ahead. They took charge. Many of them volunteered to be trained as burial team members. Many of them actually would ensure that people were washing their hands. A lot of the health education 00:37:00messages that were being sent, the community was taking charge. Ensuring that anybody at the first sign of infection, they are reported. Following up on who is coming from where. They were the first people to say look, we have a visitor and we're told this visitor is coming from an area where there may have been Ebola. Some of these were sort of kept under close observation. Again, the community had to trust the system and we, the system, the response system, had to put the community at the heart of this response. That's what happened.

Q: How do you put the community at the heart of the response? How does one do that?

GASASIRA: One, the community must trust what you are saying. I think, again, as I say it, when we said Ebola--don't expose yourself to dead bodies, and we leave 00:38:00the dead bodies there, you are shooting yourself in the foot. Or you say, at the first sign of illness, go to the nearest health worker. The health facilities have closed because health workers have fled because they fear patients. Then you shoot yourself in the foot. So you have to put the community at the heart of it. You have to be credible yourself. I think our credibility at the beginning was not that great, but as we built capacity, it improved. As I was saying, when people like Honorable Nyenswah and other leaders, other Liberian leaders, ministers, the president herself, respected community leaders; went onto the airwaves and gave information that was credible or kept people informed of what was happening; that really contributed a lot to getting the community out in the 00:39:00forefront of the response.

Q: When I think about the roles of different organizations that they came in with, CDC kind of says they were technical advisors in these countries, Liberia, Sierra Leone and Guinea. Can you tell me about defining WHO's role in the response?

GASASIRA: I think WHO and CDC being technical organizations, that's why we worked so closely together. We helped the countries to fine tune the response strategies to the country context. For example, we worked very closely on epidemiological surveillance. And having effective ways to ensure that all cases were identified in time, or suspects; all contacts were listed in time and 00:40:00followed effectively to make sure that anybody who had any contact whatsoever with a suspect case was listed and followed up and given the right information. We worked very closely in ensuring that diagnostic capacity was enhanced with mobile labs, with systems of collecting blood samples or oral swabs from dead bodies in a safe way and transporting these to the labs in the shortest time possible. We worked very closely on data management, making sure that the data pieces came together, information could flow to different people. We worked a lot on infection prevention and control in health facilities, but also in homes and in communities so that people avoided practices that would bring them in touch with bodily fluids of anybody. At that time, in fact, we really promoted 00:41:00social distancing because you didn't know who was who and who has what, and so we did a lot of these things too together. Then, in the area of training, in terms of case management, ensuring that all the Ebola treatment units had sufficient health workers who could manage patients using the recommended guidelines. We ended up training over five thousand, both national Liberian, but also a lot of the international response teams that came in to help on Liberia treatment management protocols for Ebola patients. These are some of the areas that we did work--we worked with, again, the US Army, USAID to actually build 00:42:00Ebola treatment units; with WFP [World Food Programme]; so we did build Ebola treatment units, especially here in Monrovia. Then the US Army and other US government agencies built all the other Ebola treatment units outside Monrovia. These are some of the things that we were doing.

Q: That makes sense. With what eventually became more than a few partners, I can imagine that there might be concerns about duplicating efforts or making sure that your roles are clearly defined. Were there never any conflicts or times where you had to assert your specific role?

GASASIRA: Again, during the height of the crisis, the second half of 2014 and the first half of 2015, the coordination was really strong. One factor that may have contributed to that is that actually, there was nothing else going on in the country. The rest of the economy, the rest of the livelihood had shut down, schools were closed, we had people deployed from different ministries of government working full time on the Ebola response. Coordination, at that time, was perfect, I would say. It was as the outbreak cleared and other things started coming up again that not everybody was working on Ebola. Ebola was not 00:44:00the only thing in town. [laughs] And then, a lot of us also had to work on other aspects of getting the health system up and running again to deliver normal services: immunization, care for pregnant women, malaria, and all alike. As we started going back further and further out of the heavy crisis, that's when we started falling over each other because everybody was trying to help. [laughter] We were not as tightly coordinated as we were during the outbreak, different people working on different bits and pieces of the health system recovery. Not all the information was being put on that table by everybody. That period is when things became a bit challenging.

Q: Can you give an example of one of those times when it became challenging?

GASASIRA: Yes, for example, one of the things that came to the fore as part of 00:45:00the outbreak was infection prevention and control. Suddenly, there were so many partners in this space trying to do infection prevention and control. They had gotten support from different organizations, and yeah, a lot of people got this in place and said okay, we're here to train, we're here to ensure that you're doing the right--again, I must also say that out of this experience, we started trying to put in place much stronger coordination mechanisms, and they worked to different extents. I think it helped, it helped, but there were still areas that were oversubscribed, and then there were some areas which were undersubscribed. Of course, there were big things. There were big, big ticket items like health infrastructure, the health facility infrastructure, which was not something that many partners wanted to go into. That's one, it's quite expensive; two, there's 00:46:00some skills that are required. At some point, the government was a bit frustrated that everybody was going for the softer, easier areas of the recovery, and that was a challenge.

Q: Was it one that you were able to resolve in any way, or did it just continue to be a challenge?

GASASIRA: I think there was a lot of progress made. It didn't stay an unaddressed challenge. We made a lot of progress, we had different working groups to look at different areas and to coordinate and to report, so we made some progress. We made some progress ultimately, but it was tough at some point.

Q: Was there any organization that finally stepped up and said yes, we're going to be involved in the health infrastructure; even though it's expensive, it's fundamental and we need to--

GASASIRA: Yes, yes, yes, the World Bank and the UNOPS [United Nations Office for 00:47:00Project Services] did a lot, and they are still doing, even up to now. I think up to about, to the best of my knowledge, about twenty-one hospitals have had additional infrastructure put in place in line with the recommendations for infection prevention and control. These twenty-one hospitals and health centers now have permanent triage, so that when patients come in, those that may be at risk for being infectious are handled in a safe way. So this eventually happened.

Q: Thank you. I appreciate hearing about how well coordinated things were, it's inspiring that in the midst of such a stressful, intense situation, that people would come together like that. Are there some individuals who when you think back you think, I remember this person was really great to communicate with? I personally had a great relationship with this person that helped?

GASASIRA: When I came, the first person I met on the ground from CDC was somebody that had worked in WHO before, Kevin [M.] De Cock, and he was a very senior guy. I knew him as a senior public health professional. Again, I felt a little bit worried that he would use his seniority to get his position pushed his way. He was very humble. He was very welcoming. As soon as I came, he created a space right next to him and he was really a joy to work with. Then he went and came back, I think he did three tours. It was great. As much as I say 00:49:00that we worked openly with everybody, of course, once in a while we would have one-on-one discussions and share our thoughts. And of course, several times, we never had the same opinion on things, but we could disagree in a very professional way. I think many other people who worked with him will you tell you the same thing.

Frank [J.] Mahoney was somebody I worked with in the polio days in Nigeria, so seeing him here was great because he was a great friend. He is still a great friend, but again, Frank is like--he is a dogged fighter. [laughs] He will never 00:50:00give up. He will follow an issue until he gets on top of it. When he was here, we had a particularly challenging situation where some ghetto, one of the ghettos--there was infection in the ghetto, and some of the drug users were infected, and this was really a special population to deal with. He sat down with Liberian colleagues and they thought out-of-the-box, and they thought out-of-the-box. At that time, he--I don't remember if it was him, or I don't remember who connived the terminology of "preventive quarantine." We invited 00:51:00these people from the ghettos to live in an ETU that was still being built, but was not yet in operation. They all came there, we gave them food every day, food and drink, and they could get their supplies of things from wherever would bring, but we had them in a place where we could monitor them for twenty-one days. All those who developed symptoms were separated, were tested. None of them, none of the people we brought in eventually became Ebola positive. But I remember Frank even cooking food, personally, for these people. At the end of the twenty-one days, when they were all being discharged, it was such a great thing. I remember another thing that touched me around that time was a lot of 00:52:00these people said okay, we have been exposed to you guys, we want you to help us to get out of the ghetto. We want you to help us to become useful members of society. We want to learn a skill, we don't want to go back to the life we were leading. These were things which were really amazing. But there were very many people, Athalia [S.] Christie, Desmond [E.] Williams who came in 2015. We worked as one team. We worked as one team, and I really have a lot of admiration for many of these great men and women.

Q: I've heard this story--I think actually, Dr. [Thomas R.] Frieden referred to this community that some would label them criminals.

GASASIRA: Yes.

Q: Right. But instead, you and Frank Mahoney knew that you had to work together 00:53:00with them if you wanted to stop Ebola.

GASASIRA: That is correct. That is absolutely true. Of course, I would be remiss if I don't say that there were really outstanding Liberian field workers, outstanding people who really went beyond the call of duty at the front line, sometimes even at personal risks. And did really, really outstanding work.

Q: When you think about them, are there a couple who float to the surface of your mind?

GASASIRA: Yeah, yeah, yeah, I have a great respect for Mosoka [P.] Fallah. I have a very great respect for Bernice Dahn, the minister of health. At the time 00:54:00when West Point was being quarantined, by that time she was not minister, she was chief medical officer, she went out there to West Point herself and was trying to keep the community--to calm them down. At that time, it was at great personal risk to herself. Some of the people in the ministry, Thomas [K.] Nagbe, those are people who worked very, very, very hard. Very hard indeed. Yeah, I have great respect for them.

Q: Oh, just out of curiosity, do you know if anything was able to be done to get these individuals, who you say were kind of from the ghetto, to get them into society in any way?

GASASIRA: One of the people that we worked with very, very closely at that time 00:55:00was deployed from the Ministry of Youth and Sports, at that time he was a deputy minister; right now, he's the full minister of youth and sports. We are working with him and many other organizations to use that experience to actually rehabilitate a lot of these people. Actually, it's work in progress, but the experience from the Ebola has been used in post-crisis programming, and I have every confidence that we will get several of them out. At that time, when they asked, we were not able to because at that time we were all still a little bit overwhelmed, but now this is being followed up.

Q: Can you just describe when you saw the tide kind of turn in Liberia, and what 00:56:00that felt like?

GASASIRA: Yeah, that was in early December. Initially it was--because we had been working at such a great, high, intense, high stress, high pressure, when the numbers started going down we were afraid to believe them. We said well, we don't want to relax and then be beaten again. I remember, we kept saying okay, let's wait for next week's--tomorrow's data, and then after we have a week's data, we said okay, let's wait another week before we feel that things are going--but by mid-December 2014, it was clear that the worst was behind us. Of course, the most challenging part of this outbreak was in Monrovia, in the slums, in some of these communities, difficult communities. But once we were 00:57:00able to start identifying every single chain, every single contact, and that part of the response was working like clockwork, then that's when we realized it's just a matter of time before this is over. It was very rewarding. Again, we started getting confident that yes, we are going to beat this thing, but we had to not relent. We had to improve with every single new case, with every single new chain. We had to improve the operations. Again, by the end of December, again, CDC colleagues working with WHO, they could now project every meeting we could, not only would we see the numbers and the numbers of contacts and cases, we could now project in a pictorial way the chains of transmission. By that 00:58:00time, we said yes, now we are on top of this.

Q: That makes sense, when you can actually see the individual and it's not just a huge mass.

GASASIRA: Yeah. It was fantastic. We had some colleagues, there was a colleague [Dr. Chikwe Ihekweazu] who worked with us from within WHO, he has recently been appointed the head of the Nigeria CDC [Centre for Disease Control], and he worked with a group of colleagues that were deployed from India, who had worked in the polio eradication program in India. Those guys really built the capacity of the frontline volunteers to track every single contact or suspect case and bring this information immediately. That was something that, again, by the end of the year, by January, we were confident that the worst was behind us.

Q: Right. And I think things get better in Liberia--because things got worse in Liberia first, but things got better in Liberia before they did in other countries, Sierra Leone and Guinea. What was your communication like with the WHO representatives of those countries or anybody else in those countries who was working?

GASASIRA: We used to communicate quite closely, and within the WHO network, we used to meet once every four weeks. We would either meet in Monrovia, or go to Freetown or Conakry. We met quite often, and then we had a lot of support from our regional and headquarters. We met quite often, and we'd share notes. Again, also sometimes we'd have people who have come in from either country and would have to get the information back. So actually, in very, very close 01:00:00communication. But I believe that people found--and I think maybe because Liberia was the first to be hardest hit. Our system in Liberia eventually was seen as a model, I think.

Q: Do you remember any specific advice that you were able to give?

GASASIRA: One of the specific things that we started here, which was eventually picked up by both Guinea and [Sierra Leone], was what they were calling ring IPC [infection prevention and control]. Once a case was identified, the IPC colleagues would draw a ring around the case, a geographical ring, and within that ring go to all the health facilities and assist IPC practices and reinforce what needed to be done in terms of IPC. Because initially, if a case has been 01:01:00seen in an area, more often than not, that case had been to a clinic, had been to the hospital, had had contact with the health facility. And maybe if you had had contact with that health facility, another patient at that time would have moved. It became a standard response practice, and it was called ring IPC, and I think a few articles have been written about it. That was something that was started here and that was replicated in other countries after we all shared this information.

Q: Thank you. Can you just describe what you have been up to since maybe spring of 2015, as WHO representative here in Liberia?

GASASIRA: Yeah, that's a very good question. As we realized that we were coming to the end of the Ebola outbreak, we also realized that the health system had 01:02:00been shattered to its core. Again, we worked with the Ministry of Health and all the different partners to develop a post-Ebola plan to build a resilient health system. Liberia had, prior to Ebola, it already had a ten-year health plan, 2011 to 2021, but we realized that with all that we saw in Ebola, that this plan was a decent plan but there were some areas that were not strong enough and needed to be strengthened. So we started working with a plan to complement. It's commonly called the Investment Plan for Building a Resilient Health System in Liberia. We all sat around the table over a couple of months to finalize this 01:03:00plan, and it focused, again, on the three big areas that I talked about. It has nine areas, but three were really key. The health workers: ensuring that there was a sufficient health workforce who were motivated, were well trained, and who could deliver services in a safe way. That was number one, the first big-ticket item. The second big-ticket item was the health infrastructure, and the third was the epidemic preparedness response capacity. Once this plan was articulated, all of us health partners rallied around supporting the country to implement the plan, and that's what we have been doing in WHO. Again, of course as the outbreak was controlled, we no longer have the huge numbers of people deployed 01:04:00here. We have a smaller number, but a still bigger number than was the case before the outbreak. We have been working with all the different players to ensure that this plan is implemented the best way possible, the system is strengthened so that if we get any new outbreaks, these could be timely detected and responded to. Indeed, this happened, because after Ebola was declared over in Liberia, we had three flares--two in 2015, one in 2016. We have had other outbreaks: Lassa fever, measles. The system has actually been tested and has shown to be working. It's not perfect yet by any stretch of the imagination. We still have a lot of work to do, but we feel that we are moving in the right direction.

Q: Dr. Gasasira, are there any other memories that when you look back, stand out prominently in your mind about Ebola that we haven't touched on?

GASASIRA: Yeah. One of the things that we haven't talked about is how the system collapsed and so many preventable conditions created death, how many pregnant women died because there was nobody to attend to them in childbirth; how many children died of malaria, pneumonia. In fact, that was a very, very big motivation for this plan for a resilient health system, so that if the health system is shocked by any other shock, be it an outbreak, be it a natural disaster, it should be able to withstand and continue to deliver services. That was also something that really affected a lot of us and said, look, yes, Ebola 01:06:00was a crisis, but what could we have done differently to ensure that we didn't lose so many people to other preventable conditions? That's something that was really very, very devastating, which again, I give credit to all the key players in the sector for all standing by this plan and doing their best to provide whatever, be it technical assistance, be it logistical support. We are still getting a lot of infection prevention and control supplies up to now, which is key. These are some of the things that maybe I would have wanted to add before we conclude.

Q: Thank you so much. You've given me a lot of time, and I very much appreciate this. We'll archive it on GlobalHealthChronicles.org, and with the CDC Museum. Thank you so much, Dr. Alex Gasasira, for everything.

GASASIRA: Thank you very much, Sam Robson. Thank you very much.

END