Craig Manning

Craig Manning

Q: This is Sam Robson here with Craig Manning. This is our second interview for the CDC [Centers for Disease Control and Prevention] Ebola Response Oral History Project. It is August 9th, 2016, and we're here in Atlanta, Georgia. Thank you again, Craig, for being here with me today. And a question that I had coming off of our first interview is that I think in my questioning sometimes I conflated the messaging that you were likely doing with government officials, with people in authority in health in West Africa, Guinea and Sierra Leone, with the population. And I'm sure that the messaging for those populations was different to some degree. I don't know if you can speak a little bit about how that's the case. I know with the government, you're, for instance, urging them to be fast. Ebola is huge. But when you do these radio PSAs [public service announcements], what are you saying there?

MANNING: The way I would come at a response to that would be to go back to the 00:01:00earliest days of the response before the EOC [emergency operations center] had been activated, and to speak about my first trip, along with that of my supervisor, Pierre Rollin, to get a--I think the value of starting the response to your question there is that in that period of time, that first visit to Guinea, we were communicating with everybody. That's the soup. And that's a very busy time. We found ourselves in a fortunate situation. From the communications perspective, I found myself in a fortunate position, where I have the tools--namely the microphone, the software, the recording equipment--to make public service announcements. I have with me also one of the foremost experts on 00:02:00Ebola in the world, who happens to be French-speaking. And that's a formidable little pairing, although there's other work that has to be done, and Pierre's time is very valuable. The first contacts in this visit to Guinea were the mandatory stop to meet the US ambassador to Guinea [Alexander M. Laskaris], who also introduced us onward to the president of Guinea, Alpha Conde. This is not necessarily how each and every response begins, but it is an important step that we take, and we do have to communicate, even to individuals who are educated, who are knowledgeable, and who have considerable influence and power, about what is about to happen in their country, potentially; what it is about this virus 00:03:00that needs to be spoken and shared with the public at large; and what it is that we, as a responding agency, as an invited agency of the US government, what it is we request to have at our disposal in order to be able to execute on the tasks that we've set. This is the beginning of an outbreak, it's March/April 2014, all of the hugeness of what was the response later, all that hugeness was not there. However, there was still concern on the part of the public--fortunately, because of the connections that the US embassy in Guinea had already established with local media outlets, we were quickly able to bring a noted subject matter expert, Pierre Rollin, to several radio stations and put 00:04:00him on live radio in the morning. I'm sorry, in the afternoon. Not only were those live radio sessions going out to people who were driving, to people who were going to market, to people who are home with their families, to people out of the country, those were being recorded as well, although not by me.

Pierre was doing a great job of messaging. There were others in-country who were doing the same thing. Then on my side of it, with my microphones, with my recording equipment, with my video camera, with the editing software, it occurs to me that here's Pierre, invited to speak at the US Embassy to the English-speaking audience. Let's record that. Here's Pierre, invited to speak at 00:05:00the US Embassy to the local French-speaking Guinean audience--let's record that. And this is Pierre speaking to a PowerPoint. Pierre goes over to the French Embassy, delivers the same message, Pierre goes over to the English--the UK [United Kingdom]/British Embassy and delivers the same information. But I have captured on video and audio the key messages that Pierre gave over the course of his presentation of the PowerPoint. He talks for an hour and we cook that down into little blibbets of thirty seconds, ninety seconds, sixty seconds, forty-five seconds. We create that in a number of formats, cutting it all together on the laptop and putting it out as audio files that can go to the radio stations, that we dump onto thumb drives, and also on thumb drives, we put the video messages at varying resolutions. So you can see them on a cell phone, 00:06:00you can see them on a smartphone, you can see them on television in HD [high definition], you can see them in television as standard definition. And it's the familiar messages about prevention, the familiar messages about transmission, the familiar messages that resonate with an African audience, which would be, yes, there may be fever, but it's probably malaria. Yes, there is fever, but you know, it's probably something that is not Ebola. And then instructions for people on how to, when they do care for others, how to ensure that they themselves are not becoming infected, and to report out where these cases are. But this is early days, and we're looking at a response that we imagine will be analogous to the smaller outbreaks that we would see in East Africa, in Uganda, for example. Those messages are--you know, they've stood the test, but they're not necessarily the only messages that are going to need to be created as this 00:07:00outbreak extends increasingly into the future, at least as we saw it back then.

At this point in the response, you have other kinds of communication processes which are taking place as well. So you are--there is a--I'm trying to think of the word for this: it's like a steering committee that is created by the government of Guinea, but "steering committee" is not the right word and I'm going to have to figure out what the hell the right word is. But--

Q: Specific to Ebola?

MANNING: Yes.

Q: Okay.

MANNING: Task force, I think--

Q: Task force.

MANNING: --was the proper word. And that's basically a room full of high-ranking individuals who are certainly from the government, certainly from the NGOs 00:08:00[non-governmental organizations], certainly from the embassies, perhaps even the religious communities--I don't recall. They're in a room, and I'm in that room, and Pierre's in that room, and someone is chairing that meeting, and we have to make sure that the gravity of what could unfold is conveyed to those forty-odd, fifty-odd people who are around that table. That's partly about understanding what the nature of Ebola--you know, it's the messages that you would give to general audiences. Additionally, it's messages about how we need to form groupings of concerned agencies, ministries, so that we are doing--we are sharing information collaboratively. We have to make it clear in that meeting 00:09:00that one lab needs to be willing to share the results of its diagnostic efforts with other labs as well, so that we could begin to build the epidemiologic line lists of who's hospitalized, who has not survived, who is surviving, and you get a sense of what the infrastructure ought to look like so that this outbreak becomes something that can be managed. And that's a separate communication process. I don't have the expertise to deliver that kind of information to that kind of audience, but Pierre does.

So it was clear in my mind as we stepped into what would be a longer effort that one of the primary goals at this point is not just to push information out that the public can understand and act upon, even though it's a man who speaks French perfectly fine and knows his topic forwards and back, but it's also important to 00:10:00bring around the table those who have a need for information about how to organize an outbreak response. That was the early days of what it looked like in Guinea, long before we got to the, for example, the notion to include behavioral scientists to guide us in the development of messages or to understand better why communities are hesitant to act on information that they're being given. That's later in the process, whereas the upstream stuff concerns the development of a task force and the conduits for bringing in resources to aid in the response. Does that kind of let you see that there's a multi-level--

Q: It does.

MANNING: --piece going on here on the communications side?

Q: Oh, it absolutely does. And I'm hoping--let's see. Do you--and I'm sure that there were moments--you talked in the first interview especially about how it 00:11:00can be so hard to convince people that this is urgent, maybe even more urgent than cholera. You can't just take weekends off, this is a seven-day-a-week, work-hard-now thing. I don't know if you can recall a time when someone at one of these meetings just didn't get the urgency of Ebola?

MANNING: Oh, okay. It's like a specific thought--a specific observation.

Q: Sure.

MANNING: When I was at UNICEF [United Nations Children's Fund] in Sierra Leone, meeting with local staff there, the sea change in thinking that needs to start 00:12:00to pervade the responders--that change was not taking place fast enough. I can't necessarily fault people for that, because on a certain level, Ebola is just another--it's the new kid on the block. They've got immunization programs going, they've got a cholera outbreak up-country, they have yellow fever, they have malaria, they have maternal and child health, they have HIV [human immunodeficiency virus], and on and on and on. We are in some ways asking them to willingly commit to a paradigm shift, where everything that they're going to be doing is going to be shuffled.

In one instance I was talking to a woman named Katharine Owen, who was the in-country director for the Irish NGO [nongovernmental organization] called GOAL. And in my first meeting with her, she listed out the numerous programs 00:13:00that GOAL was engaged in, and GOAL has been in Sierra Leone at that point for maybe seventeen years. They've got a great track record, they have their processes worked out. They're doing very creative engagements. And that showed me how capable GOAL was. I talked to her several months later, and I said, "What's it like there, and how are your programs going?" And she basically said, "We've shut a good many of them down, because we had to do a complete pivot in order to be able to address Ebola." So even if there may not be the understanding of there being a need for a sea change by organizations, some come around to the realization that they simply have to turn the ship in another direction and either park programs that they have committed budget resources for 00:14:00and have personnel plans for and have goals of their own, and then redirect that. And that's not a small shift for NGOs such as GOAL, and it is especially a challenge for governments, and it is certainly a challenge for the UN [United Nations] organizations like UNICEF that are operating in that environment as well. So yes, people come to understand, and I'm not sure whether it's the photographs of bodies in the street or whether it's the conversations that they're hearing at their neighbor's or whether it's the staff who are refusing to work at hospitals that ultimately starts to paint for people, in the public and in positions of responsibility and authority, a more comprehensive sense that this is a really dangerous situation, the likes of which we have not seen. 00:15:00Then at a certain point, people it seemed to me were well aware of that. But still, the systems do need some time to catch up, because you can message to people that they need to go to the Ebola treatment centers, but if the Ebola treatment centers are not yet finished and open, then you may have to recognize that you could do more harm than good. That's a terrible predicament to be in. [laughter] Is that kind of where this--

Q: Yeah, absolutely, thank you. I mean, I know it's been a while back now, but do you remember when you might have had these conversations with Katharine Owen?

MANNING: The conversation with Katharine Owen, that's in Sierra Leone, was July of 2014, the first one, where I met her at the hotel that we were staying at, and looking over the veranda at the harbor below Freetown in Sierra Leone on a 00:16:00beautiful day in the warmth and elevation where we were, sipping a Coke at a table with an awning with somebody coming to wait on us. And it seems on a certain level that nothing is amiss in the world at that moment, and yet I'm bringing news to people about what could happen. I'm not an expert in predicting any kind of future, but I'm trying to get as close as I can in my word choice to explain to people the nature of this virus and what we've seen elsewhere in the world.

I also was keen to explain and to find an advocate, as it turned out later. I ended up meeting, during the same visit where I met Katharine Owen of GOAL, I 00:17:00met also with George Ferguson of BBC [British Broadcasting Corporation] Media Action. He was a Brit living and working in Sierra Leone, working for BBC Media Action, which is--it's an NGO flying under the BBC flag, which, in this instance, meant that for Sierra Leone, George and his staff were responsible for training journalists and for bringing in the technology that allowed information to move outward. So George and I had a conversation during that period as well, and I found him to be a very engaged and active and curious man, and we worked all the way down through the disease process, through the diagnostic testing, through the clinical management of patients--all of the stuff in--the other 00:18:00experience in Africa, with Ebola. And I think he was left with the impression that, early on, he had met someone in the form of me who knew his way around the topic, and I think enabled him to have some confidence that one of the things that we should next be doing is training journalists. So George organized, in July of 2014, a training for journalists from the different counties in--areas of Sierra Leone, where they had BBC Media Action people, where they had the funding to pull them into Freetown, and he and I and somebody from UNICEF, Mr. Conte, we trained journalists with the same messages that we had been training. George played a very pivotal role at a rather golden but brief moment in Sierra 00:19:00Leone, where he took information from only one person, me, and built a response around that. We tried to fund those guys but we couldn't make that happen, but they were scrounging for money because they recognized they need to put their messages on CD [compact disc], they need to maybe repair some generators, they maybe needed to buy some diesel to keep those generators running farther out. But to his enormous credit, he got on that train real quick, and he moved real fast. So these two people that I speak of--Katharine Owen from GOAL and George Ferguson of BBC Media Action--these guys met with us, the team that was in-country at the time and from CDC, and we came around to the notion of creating this thing called the SMAC, the Social Mobilization Action Committee, 00:20:00or Consortium--I forget what the hell it is. But that consisted of ourselves, as the CDC; it was GOAL; it was BBC Media Action; and another group called Restless Development, which was kind of the boots-on-the-ground piece of that--which enabled us to see for ourselves, when we stopped to reflect back on what it is we had done by agreeing to convene and call this thing the S-M-A-C, the SMAC--we were able to see that we had enough knowledge and capacity to really begin to move out into the community. We had CDC with the technical knowledge and some of the money, we had GOAL, a partner with deep experience, engaging on public health issues in Sierra Leone, we had BBC Media Action, which was the media 00:21:00piece of this with the tools to reach out into the wider community via radio and the ability to send electronic files electronically as email attachments to the more distant stations, and finally, we had Restless Development, which was the kind of boots-on-the-ground folks. That was an entity which kind of enabled us to cover the waterfront--not that there was any exclusion of the Ministry of Health, not that there was any exclusion of UNICEF, but rather it was just kind of an amping up of the overall capacity to respond. The communicating that went on within that at that stage was mostly about building capacity. How are we going to organize it? Who's going to do what? Yes, there are going to need to be messages, yes, there's going to need to be behavioral science, yes, there's 00:22:00going to need to be an understanding of community, ethnicity, language, and all of that, but the bright people were around the table, it seemed. And we had, I think, as clear an idea as we could possibly have had at that point in time of what we could aspire to achieve. I think we set about it in earnest and quickly and quite seriously.

Q: Yeah. I think one exciting thing that you're describing that I'm picking up on, I think--we talked before about how the national authorities, you know, the Ministry of Health, is not always the only authority in a country, or it never really is--

MANNING: Yeah.

Q: --that there are regional and tribal authorities that exist in parallel. And it sounds like what you're saying is that SMAC organized itself in such a way that it could reach, not just the Ministry of Health, but those other kinds of authorities. Is that right?

MANNING: I think that's accurate. I don't want to overstate our reach, because 00:23:00one has to keep in mind that other agencies are operating in the country, and in this environment, where information is being created and moved at incredibly quick rates and speeds, it would be wrong to think that we were in charge of something as grand as the collective communications response. I think we simply had a strong concept that could pull resources, pull money, create ideas, develop messages, implement, evaluate, and modify messages across--all the tools that we needed to get rolling were there. The proof in the pudding of the value of SMAC, of the SMAC, is seen in the fact that it was an entity that engaged 00:24:00and, indeed, gained considerable visibility across the longer term of the outbreak. As people came in on behalf of the health promotion team to serve as team leads or to serve as behavioral scientists or whatever, there seemed already to be a structure that could absorb the skills and put them into the field, whether outside the city or whether in the city. There could be press conferences, there could be training of journalists, there could be jingles on the radio, there could be a specific program called something like "Ebola Big Idea of the Week." And Kathy [Hageman] can speak with far more detailed knowledge about that than I can. But it attests in my mind to the value of 00:25:00having a communications--a little juggernaut of sorts, at the beginning, that on a certain level is gestating some of the strong ideas that over time give evidence to its having been a good idea, because that thing lasted for some time, it achieved a degree of recognition and approval, and no matter who was managing it, no matter who was team lead for health promotion, that SMAC really had some impact. I found myself on other occasions envying perhaps the--you know, I wish there had been something comparable to that in Guinea. I wish that there had been something comparable to that model that could have been created in Liberia. And if you asked me, well, why not? There's no simple answer, but I 00:26:00never did find, either in Guinea or Liberia, something that was comparable to GOAL, nor something comparable to BBC. Not to say those things weren't there, but I didn't uncover them. So it would have been great had there--in other words, we had a wonderful example of how things can work in the middle of very challenging times. Wouldn't it have been nice to copy-and-paste that into Guinea? Wouldn't it have been nice to copy-and-paste that into Liberia? And we had other things that were working strongly, but honestly, it seems like the most coherent and robust and persistent of the outbreak response tools in coms [communications] was the SMAC in Sierra Leone.

Q: When was it that SMAC really got started running? Because when I imagine health promotions and Kathy coming in, it's kind of like January of 2015.

MANNING: It's later.

Q: Yeah.

MANNING: Yeah, it's later. But the team that was around the table in July of 2014 from CDC, that was myself, it was Vance [R.] Brown, and Mark [J.] Pelletier. And the conversations that were taking place with Katharine Owen and George Ferguson and Jamie, I forget his last name [note: Bedson], from Restless Development--those were happening, I believe, in July of 2014. And I hope I'm correct in remembering it that way.

The time from idea to money in hand to projects funded to work being undertaken, it wouldn't surpri-- by the time this thing called SMAC is something everybody in-country knows, that was long after I had left. And the time it took to put 00:28:00that infrastructure together--for lack of a better word, "infrastructure"--it might have been months when, you know, the SMAC was simply an idea that was--we don't know whether this thing will grow or not. [laughter] And you start this thing, and you think, will it achieve the goals that we intend for it to achieve? Will it have the resources? Will it be capably guided? Will it be supported? Will it be regarded by the government as a kind of renegade organization? That clearly was not what was happening, but it did cross my mind to wonder that. And it was--I can't speak for the speed, I suppose, with which it grew and expanded, but by the time we were at the end of that same year, it was rolling. That's a very imperfect answer, but I think I can't give you a 00:29:00better one, actually.

Q: No, no, I appreciate it. Thank you. And I know that, of course, in a response, there's going to be competing things that draw people's attention, just the explosion in cases, for one. [laughter] But--so correct me if my perception is off, but it sounds like there's something that was really new in the creation of CDC's health promotions team. You mentioned in the first interview that it, you know, creating its own little box in the organizational chart, just like epidemiology--I don't know if the team "health promotions" has been around a long time, or if it started to take on new meaning here, or if it was completely new. Can you describe the development of the health promotions team in Sierra Leone?

MANNING: Yeah. Just as a small correction, I don't put an S on "promotions," I just leave it as "promotion."

Q: Oh. "Promotion." Thank you.

MANNING: Neither here nor there, honestly.

Q: Okay. [laughter] Appreciate it.

MANNING: Yeah, you have that story, you know, from before in chatting, where we were talking about just putting that box on the org [organizational] chart and deciding that it would be called "health promotion." I did learn later that, despite the fact that I had thought that there was not really something that was called, or was analogous, to health promotion occurring at CDC, in fact, that has been around for a time. I ended up talking with Susan [J.] Robinson, who was one of the team leads for the health promotion team in Guinea, and back in her earlier days here at CDC, there was something going on that she was referring to as "health promotion." So somewhere in the org chart of CDC, there has been, or may even now be, a health promotion component. I was unaware of that at the time 00:31:00when I was staring at the org chart, wondering what I should do in terms of putting a box there. So the thought that I had, as best I can recollect, was--I had been on a response to an Ebola outbreak in '07 in western Uganda, in Bundibugyo. And because I went over there as part of the Viral Special Pathogens Branch, as the only health communications specialist around, I had enormous responsibility, in one sense, and had to decide with input from my boss, Pierre, what it was my focus would be. And in some ways, it's kind of stark and it's 00:32:00kind of simple. You can be the media affairs person, and you can file stories about what the Ministry of Health is doing and how CDC is collaborating with the Ministry of Health and how CDC is supporting diagnostics and how CDC is supporting epi [epidemiology]. And you can send all that back to Atlanta. And there's nothing wrong with that, but the other piece of it that is not happening is the opportunity to reach into the community and to leverage all of the knowledge that CDC can bring to bear--if we aren't leveraging that and pushing out messages into the community and understanding what that community needs, what that community fears, it seems like we're forfeiting an opportunity.

So while the idea that Doctors Without Borders, MSF, is out there doing clinical care and messaging in the community--while an idea such as that is not new to MSF [Medecins Sans Frontieres], and while it's not new to UNICEF, it's a little 00:33:00bit of a paradigm shift for CDC. Not that I was necessarily aware of that back in '07--I was simply thinking, I'm in a small community, and I need to find who are the leaders and the opinion-shapers in this community, and I've got to make available the information that is part and parcel of what I'm expected to do, because I work in the Viral Special Pathogens Branch. And I toted along the same laptop that I was using in West Africa, and again, we did the same thing. We were finding those who could translate the messages into the local languages that were being spoken there.

So that's the model, in my mind, for how it ought to look in West Africa, because all of what was taking place in Uganda was me going from village to village, meeting with people, doing Q-and-A [question and answer sessions], 00:34:00doing everything that I suppose fits nicely under the heading of social mobilization, but I think of this as health promotion. And it seemed, by the time I was staring at the org chart early on in this outbreak, wondering what we would call this, I thought social mobilization was not it. I thought health education was not it. I thought media affairs was not it. It seemed more like health promotion was the name that most aptly belonged in that box. And so you have a health promotion team. And I think maybe it would be a little bit of a harder sell to encourage people to use social mobilization, because that seems quite tangential, at least to many, relative to what CDC's core strengths are.

The insight that I've wanted to make use of, and it's indeed a kind of privilege, because in our branch I work very closely with one of the foremost 00:35:00subject matter experts in Ebola in the whole wide world, I have a lot of information that other people would not have such easy access to. But I can walk into Pierre's office and say, "I've got a question about diagnostics," and within thirty seconds I have an answer. The expediency that comes of working in close proximity to the subject matter experts had everything to do with my view of how it can be organized in the Ebola response in West Africa. I cannot talk with anywhere near the expertise that Pierre can, but I can bring information to people like George Ferguson, of BBC, enough of an understanding of how this whole thing works to not just be a fellow who's reciting facts to George and expecting George to run with it, but actually to sort of put some passion into 00:36:00it and say what we have seen elsewhere, what my own experience tells me, what I see from Pierre's comments, and somehow that proximity to Pierre over these years has kind of rubbed off so that I have a lot of information that I can throw out, and hopefully some of that understanding includes how to organize what it is I do in the wider context of what everyone else is doing, and to have that be hopefully something which contributes to the response. Oh, I'm sorry. Long answer to a short question.

Q: No, no, that was good. And you've been answering this next question, probably, for the last--well, our entire interview. But I kind of want to ask you point-blank, if that's okay. How do you define health promotions?

MANNING: Those activities involving a multidisciplinary approach to conveying 00:37:00actionable information in a culturally sensitive manner to audiences who can act upon that. And I think I can kind of leave it at that, actually. I think that's pretty succinct.

Q: Yeah. [laughter] Glad I asked.

MANNING: In the word "multidisciplinary" lies, you know, layers and layers of--what should I say? There was so much going on in this that--I don't mean to sell it short by describing it with such brevity, but I think that's the deal. Jana Telfer, who--and you may talk with her later on--has created a document 00:38:00which is a long kind of forensic look at what the health promotion team was up to. She herself dives into these various words or phrases that are used in this discourse, like "social mobilization," like "health education," like "health promotion," etcetera. She tries to distinguish clearly, and I think this is admirable, one of these sets of activities from another. I think you can do that, but I do think that it sort of changes over time, and to be absolutely honest, I think the West Africa response has set us all back on our heels and made very relevant the--that it's necessary to investigate further how it is we manage ourselves in these circumstances, regardless of what we call ourselves. [laughter] But also, how we engage among ourselves and then in-country. For me, 00:39:00health promotion is what we did in West Africa, but it was almost--it wasn't like I was--many of the names that have been used over the years have relevance here, but at the scale of this response in West Africa, that was a pretty--the naming convention was one of the lesser priorities. [laughter]

Q: Right. No doubt, no doubt. Okay, well, I appreciate that. Thank you, Craig. This is switching gears a little bit, but I'm wondering if you can describe some of the behavioral scientists who you worked with.

MANNING: There were two that I did not work closely with on a daily basis, but with whom I worked and for whom I have enduring admiration. Actually, there were several, and a couple of them are CDC people, but the person who comes to mind 00:40:00most readily in terms of a social scientist is a woman named Dr. Juliet Bedford. She's not a CDC person--she's an Oxford [University] PhD in anthropology, and she's based in England, and she came over here early on in the outbreak to encourage us to think very carefully about the anthropological component.

Q: She came to Atlanta?

MANNING: She came to Atlanta. Along with another woman whose first name is Sharon, but I forget her last name, from the University of Miami.

Q: Sharon Abramowitz?

MANNING: Yes.

Q: Okay.

MANNING: So those guys paired up--I believe Sharon was able to get into CDC; I believe Juliet, by virtue of being from England, was not allowed into the meetings, but she connected from her hotel to the meetings. And then I met her later for lunch across the street. So being an anthropology undergraduate 00:41:00myself, I have kind of a kinship with people who take the anthropological perspective to heart. And Juliet was keen to emphasize to CDC, as was Sharon, that an understanding of the population to whom we are communicating is going to be fundamental in West Africa to making messages that actually are understood and acted upon. Juliet was even more specific, in that as the outbreak evolved over days and weeks and months, she began to put out short summaries, little two-pagers, of cultural attitudes towards death, for example; cultural attitudes towards community, cultural attitudes towards sickness and health, that were very, very particular and that enabled us to incorporate those into our messaging.

The other name, of course, would be Kathy Hageman. I'm sure she can tell you far 00:42:00better than I can what it is she has done, but she's been a really--a person who was very pivotal in making the case for the value of the behavioral sciences, in any of its facets--from quantitative KAP [knowledge, attitudes, and practice] studies to the more qualitative interviews with people. And then lastly, another CDC person, Neetu [S.] Abad, who was very actively engaged in the Viral Persistence Study, and making sure to help the CDC virologists and epidemiologists better engage with the population there. Who have been sick and 00:43:00who have recovered, who are providing semen samples, who are valuable allies, in one sense, enabling us to better understand physiologically what's going on in the aftermath of an Ebola outbreak, with respect to individuals who, some two hundred fifty days subsequent to recovery, are still showing signs of potentially being infectious. Neetu was giving health messages to these men about abstinence or condoms or all those topics. Basically, there was no one there before her who imagined it, and she had the breadth of vision to really 00:44:00grasp that this population needs to be communicated with, and here are some messages for them. I think she's served the agency exceedingly well in having put to use her PhD in--I forget what it was--psychology, I think--as a behavioral science person. Again, practical activity developed by someone who was the only person around who was seeing that need, and yet stepping forward to really nail it.

Q: Right. And of course the Viral Persistence Study and everything, that would have been 2015 as part of the response, or even this year, 2016?

MANNING: It's still ongoing, as I understand it.

Q: And--but so Dr. Juliet Bedford and Dr. Sharon Abramowitz, when would they have been--?

MANNING: Juliet--I don't know what became of Sharon, but I do know that Juliet was hired at one point by UNMEER [United Nations Ebola Emergency Response] and 00:45:00that a New York Times article by someone writing about--the title of it was something like, "I Love the UN, But I Hate Its Bureaucracy"--she was mentioned as--not by name, but just as this worth-her-weight-in-gold individual working for UNMEER in West Africa, because of her insights into how you communicate with people. Juliet--the last time I saw her was November of last year at a meeting at WHO [World Health Organization] in Geneva, and she was working directly on the Zika response. Again, organizing different KAP studies to better understand what people understand, their knowledge, their attitudes, their practices with respect to health, and again, really encouraging WHO to step forward in this arena and to emphasize it directly. So I've not talked with her since, but her 00:46:00description of herself is that she is an applied anthropologist, which is to say, not necessarily inclined to write long pieces that take some time to publish, but rather to use knowledge gathered in the field today in a manner that it can be applied tomorrow. So I think she's to be hugely credited for that--very insightful, very talented lady.

Q: Thank you, Craig. I'm going to switch gears again: totally different topic. You mentioned that while you were in Sierra Leone, unless it was Guinea--must have been Sierra Leone--Dr. Sanjay Gupta, from CNN, visited.

MANNING: That was Guinea. That was Guinea.

Q: Oh, that was Guinea.

MANNING: Yeah.

Q: Okay. When was that?

MANNING: [pause] I don't think it was my first visit. I'm not exactly clear. But 00:47:00I'm pretty sure I can say to you that it was not the first visit, because some of the activities that he wanted to film were probably not up and running yet.

Q: What did he want to film?

MANNING: Contact tracing. That's when health professionals go out into the community looking for cases. It's quite visual and it's quite dramatic because you can find--you know, when contact tracing teams go out into the community, and particularly as they go out into the community of Conakry, the capital city, they may find sick people, they may find dead bodies, they may find people who want to hide the sick people, they may find people who want to hide the dead bodies, they may find that the contact tracing teams are unwelcome and are greeted with hostility or threatened. So Sanjay--this might have been July of 00:48:002014--was there, and he interviewed Pierre. The other sensitive topic at the time was around the issue of suspending flights into Guinea. Sanjay's point was that, well, certainly someone could get on a plane with Ebola in Guinea and enter Europe and then travel onward to the United States, etcetera. So he interviewed Pierre on that topic, and Pierre was pretty quick to put down that line of argument because the capacities of the developed countries to handle arriving Ebola cases, even if they're undeclared, would still be such that there would be limited transmission before there was anything like what was going on in West Africa. So then [laughs] Sanjay came to me and said, "I'd like to film 00:49:00the contact tracing." And I said, "We've just heard from WHO that they don't want anybody going out. They don't want any media accompanying these contact tracing teams because it's already a sensitive issue, and having a crew filming this thing, especially when you don't look anything like the people who are there, that's not going to add to the ease, and indeed it may put the contact tracers at risk. It may exacerbate an already tense situation." He wasn't happy about that, and he said that he had kind of been led to think, from the highest authority in WHO, that he would be supported in this effort, and he had been--I think he had dinner with--he had some kind of okay from over here to pursue this as well, and I think he found it frustrating when I told him that I didn't see 00:50:00how there was going to be any way he could pull this off, because I was not going to tell him where the contact tracing teams were, not that I even knew. I don't know whether it would have been good news--it wouldn't have been, perhaps, terribly relevant to watch this on TV. It's certainly something, as health professionals, you want to see what it looks like when people are doing contact tracing, but that's not something which can be allowed under each and every circumstance, especially if eventually he puts himself in harm's way or a crew member is threatened or harmed, and it seemed at a certain point the nature of this inquiry on the part of the contact tracers was potentially inflammatory enough to make people act out against them. That wouldn't have been good if that showed up on CNN. [laughter] As much as he might have wanted to have it show up 00:51:00on CNN. So I do think he went over to MSF in Conakry, because they had a facility at the Donka Hospital where they were treating patients, and he was able to go through the gowning-up process, as if he were to be going into isolation.

Q: Gotcha. Which is also, of course, a very visual, interesting thing to--

MANNING: Yeah. I don't think he got in--I think he was able to suit up and walk toward the treatment area, but I don't believe he was allowed to go in.

Q: Gotcha. Okay. [pause] Can you give me an example of a time when CDC, in any 00:52:00of the countries that you worked, might have stumbled when it came to culturally appropriate health policies or messages?

MANNING: Yeah. Let me think. Well, the one I was just about to give you was not necessarily uniquely CDC. Let me think--think hard on this. [pause] I can think 00:53:00of something that's not the best example, but--and there may be others who combined, if you ask them the same question, they can answer differently. But the place where I thought we were walking a funny line was when I reached out to a recording studio in Sierra Leone with our scripts and with our messages, and we paid this fellow, and his job was to bring in people who spoke the main language and then any of the other languages in the area, and he himself was speaking in the local language that was spoken in Freetown. And he played me 00:54:00back the first recordings. He was really exclaiming, he was really declaiming--he was, like, take a used-car salesman and give him three Red Bulls. This was intense messaging. And on playback, I thought, my god, we're not doing anything to bring about a sense of calm. We're screaming at people. And even though the messages are good messages and they aren't intended to provoke further anxiety, I had to ask him--I said, "Is this really culturally appropriate? Because I don't know." And he said, "Go listen to the radio in town," because this guy does other radio work as well. And I did listen, and 00:55:00it's all the same. They could be selling paper towels, and they're just banging on you vocally. And these messages that were coming out and being recorded by him were, to my ears, very strident. But when you put them in the context of, you're driving around with your driver and you listen to the radio, then he just sounds like everybody else on the radio, and that calmed my nerves. The other voiceover talent that were doing the other languages, they weren't as strident as him, but there was still a kind of intense projection--and I saw that on live radio, too. There was this occasional inclination to cross-examine the subject matter expert, as if that individual was hiding something. And we as newcomers into that culture were not necessarily expecting that. We're not expected to be 00:56:00accorded enormous, unlimited respect, but rather we were expected to be listened to and not necessarily challenged. So I kind of got it, that there was more to the conversation than just a simple narrating of calming messages. That wasn't going to happen. And I'm convinced that nobody would have listened. Everybody would have thought, what a waste of time, and they wouldn't have paid any attention. So I don't think it was a misstep, I think it was simply a kind of learning process where it takes you right to the edge of what you think is acceptable. At some point we have to embrace other cultures. But at the same time, we have a kind of organic line that has to do with how we've been brought up, and we just don't know what to do when we get to the fifty-yard-line of that particular line. Do we say, no, let's start over? Or do we chill out and let them go with what they say is correct? Sometimes it's absolutely easy to trust 00:57:00that, and other times it's not.

Q: I have to apologize--I probably missed this. What was the message that the individual was sharing?

MANNING: Oh, sorry, I didn't make that clear. When we rented that recording studio, we had in mind to take all of the Ebola scripts on prevention, transmission, treatment, etcetera, and have those rendered at this studio into the other languages that are spoken in Sierra Leone. And then George from BBC Media Action was going to distribute those out to the respective parts of the country where those languages were spoken. So does that make sense?

Q: Yeah.

MANNING: Okay. Did--[overlapping dialogue]

Q: No, yeah, absolutely. There are all kinds of messages.

MANNING: Yeah, yeah. I mean, it's the usual.

Q: The whole gamut.

MANNING: It's the transmission, prevention, symptoms, trying--you know, yada yada yada yada. And so we had, I don't know what it was--seven languages times ten messages or something like that. So we have seventy-odd messages, all on 00:58:00my--you know, I have a CD collection of Ebola messages. [laughter] In multiple languages.

Q: I'm guessing that messaging around burial practices must have been difficult. I've heard people, just like people I know outside of CDC, talking about the spread of Ebola as if it's these ignorant people with their backwards burial practices, which is offensive and wrong, but carries a nugget of truth, in that washing bodies which were extremely viremic spread Ebola. How did you manage that line between trying to share that message but also being respectful of the culture?

MANNING: Yeah. It can be calamitous, it can be painful, and it can destroy communities. Because you're asking people, in the middle of circumstances that they're trying very hard to understand and for which they have some functioning logical, you know, cognitive frame through which to view it, you're asking them to do something that involves creating a future that threatens their community with its very existence. When you have failed to send a loved one into the afterlife in the proper manner and the basis for the community is in part 01:00:00respecting and remaining in contact with those people, then you've brought shame upon your community, and why should there be a community, let's go someplace else. To say nothing of the stigmatization inflicted upon those people who live in--who had Ebola and recovered. And to make matters worse, you're asking people to do this in a hell of a hurry, because with Ebola, hours and days matter. So this is the kind of cultural line of scrimmage that Ebola brings to the responses. I know this from Uganda, and I know from what my colleagues have told me prior to the outbreak in Uganda in '07, prior to my being at CDC, that speed 01:01:00is of the essence. What they don't tell you is the culture is a casualty of that speed. And I think there can be a protracted debate on how you strike that balance between the urgency of action and the perilous consequences that could ensue if the cultural piece is ignored. In some communities, in Guinea, for example, I remember Pierre meeting with imams and saying, let's see if we can find a middle ground such that bodies will be brought to the mosque so that the particular group of people in that mosque, who are trained and wear the proper gear, can disinfect those bodies, and then burials can proceed, as in in 01:02:00accordance with Islam. And that seemed to be an acceptable option. Was it practiced everywhere throughout Guinea where there were practitioners of Islam? I don't know. In those religions or faiths or practices where there is direct contact with bodies, it's a negotiation to see what people can let go of and what people can't let go of. What comes out of this, to my understanding, is that there is a willingness, and the community, one voice at a time, perhaps, gets behind the understanding that if we aren't going to change our habits, then the outbreak will be perpetuated. And it's not everybody who agrees with that at 01:03:00the outset; it's a certain set of people--you know, some people will and some people will just have no part of it. And you will have, as there were, I believe, in Sierra Leone, people going to gravesites, exhuming the bodies, and then having a proper--"proper," in quotations--funeral service for that individual. That was scary, because it's a measure of how tenaciously people hold to culture, while at the same time it reflects that we maybe could have negotiated that a little bit better, so that the likelihood of that were less. There's no doubt in my mind that you put people up against a wall when you have something as urgent as Ebola, and you're telling them, this is something which you've not seen before, this is something which does not fit within your 01:04:00paradigm, and you have people in your country who are going to tell you what to do from positions of authority. You may not like authority because of what authority has done in the past, and they're going to tell you to do everything in a hurry, and you're not going to necessarily see the people whom you know who have died. And there's going to be no explaining of what happened to them--no one's going to know where they are, and we ask you to go along with this, for the benefit of bringing the outbreak to a close. That's a huge, insane demand to place upon people who are already challenged with everything else in their lives. And I say that with abundant compassion, because if we ourselves were told, you can't drive to work on [Interstate] 285, I mean, people would go crazy. [laughter] It's enough when snow falls on 285. But this is--I don't mean to equate these distinctions, but we can find them in our own culture when we are asked to do something profoundly opposite to what makes sense.

Q: Right. I appreciate the example of Pierre speaking with the imams. Were there 01:05:00other times where you felt you had to negotiate this line that you can recall?

MANNING: I don't recall any examples of my doing that.

Q: Sure.

MANNING: [pause] I believe there's a story--and Kathy Hageman would know this, and Wendy [A.] Holmes would as well--from Sierra Leone with respect to the ambulances. And you might have heard that story already--

Q: I've heard about the ambulance--yeah.

MANNING: Yeah.

Q: I think the ambulance is a great example. I think--

MANNING: Yeah. I think it is pretty illustrative, actually.

Q: And I think the color of the burial bags also being one of them--not black but white--

MANNING: Yes. Yeah.

Q: --that's interesting. Okay. Thank you. One thing I don't understand super well, and I apologize for that, is how you contribute to the response when you 01:06:00come back to Atlanta. I know you have meetings, you talk to people, but what can you actually accomplish from back here?

MANNING: Oh, that's a really great question, actually. Because I stared that one in the face for a long time, and watched it grow from a, you know, a guy who works for the Viral Special Pathogens Branch, here's the responder, and see that morph into something where you have teams, you have training, you have support while people are in the field, you have integration with other teams, you have coordination issues across the countries, so that if something's been created 01:07:00for Liberia, it may have relevance in Guinea.

There needed to be a health promotion hub in Atlanta for a number of reasons, one of which is we, as health promotion, have to attend the meetings of the taskforce, have to understand what the epi people are doing, what the diagnostics people are doing, what they might actually need, and we may have resources that they can benefit by having. They're sharing out their information, and we may say, based on what we heard in the phone call this morning, over there in Guinea, they're going to be sending some epis [epidemiologists] up to such-and-such a place. Why not send a health promotion person who's already there with them? So you have a training responsibility for 01:08:00the people who are coming in--you put them in front of those who have returned and they have a conversation--there's a handoff--some of that happens in-country and some of it takes place in Atlanta. We could bring people into the team room for the health promotion team and prepare them prior to their going in the field so they could understand what it is we're able to do back in Atlanta. So if someone calls up from Guinea and says, we need a poster, well, then, we can get that poster happening, and all of the rigmarole that would be insanely hard to deal with from in-country, we can coordinate that. Our job was to just have it be possible that when you call the health promotion team, you got somebody who was your country's person. Like a desk officer, as it were, for each individual country. And we broke out people to support that.

Then the other piece is simply keeping track of who's where and who's coming through the pipeline, who does speak French but doesn't speak well, who does, who was in Peace Corps but in Mali, and to try to fit people into the slots that are needed. And also, if people are struggling in-country, to pull them back out if they request that, and they're absolutely free to without any kind of stigma or without a moment's hesitation. And to advocate for moving money, if we have to move money. And to kind of run it from Atlanta, knowing that part of this is illusory, because the teams in-country are amply, abundantly busy. So when they have to get on the phone and talk to us for forty-five minutes once a week, they're pissed off because they just don't have the frigging time to do--pardon me, but they don't have the time to do that. There's an urgency to what--and 01:10:00they will look back to Atlanta and say, because I've had this experience too, "You guys are clueless, you guys are [unclear], you guys aren't helping," and you know, yadda yadda. So we need to be there backing them up, but not in a way that's intrusive. If they're asking for, "Hey, these two people aren't getting along," that gets handed back to us, and we have to address that. Or we find out that someone was not working out well, and we don't send that person out again.

So while it seemed, perhaps, from the vantage point of someone sitting in Atlanta, that Atlanta health promotion ran the teams [in-country], I would think that's a bit less like that than--it's a constant interaction and exchange, and 01:11:00we're guiding them in terms of what they can do, we're supporting them with what they wish to do, they need to put a booklet together, let us help you, but--they're kind of driving the bus, we have to--you know, we informed them--and that was not an adversarial process. It didn't feel top-down to me. It felt like, because I had been in-country several times, that--I hoped that when people were calling back here, they were getting someone who could appreciate the craziness of what it is like for them, while at the same time trying to provide a sense of order and continuity and directionality so that they do feel supported while they're there.

The funny part, the odd challenge, is when you have something which is as together as the SMAC was, and they've got the Ebola Big Idea of the Week, then you're already moving into a well-oiled machine, or so it seemed to me. So I 01:12:00didn't have to worry about what Kathy was doing, because Kathy was just doing a bang-up job. Whereas in Guinea, we have a very different and bumpier ride, because we have in the one instance, for example, someone working as team lead who is very independent and comes from a more media background. And then the next person who follows that person is someone who comes from a strong behavioral scientist, very top-down, very management-oriented, very--thinks in boxes and progress and charts, and the second person might have no wish to continue the work that the first person has started. And that's infuriating. At the same time, when that person who's going to be there, running something for four weeks or six weeks, the job is to support them. If they're just constitutionally not able--they're also facing a different set of circumstances, because what was true four weeks ago isn't true today, and in four weeks that 01:13:00will change. So the sense that people report back on is that there wasn't much solid ground. They're always saying, should I be working on this or should I be working on that? Should I be focusing on this? What about survivors? This emerging theme of survivors? Or we work in this one district, it means we can do something there, but we can't do something someplace else. Or we want to be able to do something which is more statistical, and we think that it has a bearing on what we might do, but we don't know if it will be relevant in two weeks. You're trying to read these multiple hoses at the same time and trying to provide some guidance. It's far from clear what particular priorities, on a very granular level, what particular priorities should be trumping what other possibilities. You leave that to the team leads. Do we have to do the Viral Persistence Study 01:14:00as an effort where there was a behavioral scientist with considerable skill? If we didn't have such a person, I think we'd be fine, but she really contributed to the effort. Might she have been better placed someplace in some other county? I don't know the answer to that--probably she could have done great work there as well. But we're not solving each and every problem in each and every district for each and every place. We pick as wisely as we can.

Q: Gotcha. I think I have a much better understanding of the dynamic between Atlanta and the field, at least when it comes to health promotion now, so thank you for that.

MANNING: I think it was like that for the other teams as well. I could see when I sat in those meetings here that people task themselves pretty competently in-country and then the managing [from Atlanta] is just to prevent wheels from 01:15:00falling off. [laughter]

Q: I have just a couple other questions, if that's okay.

MANNING: Yeah.

Q: You mentioned previously that you're one of the people in the response that--recognizing that it's important to do things now and to keep doing them and just have to be really passionate and focused, that when you transition out of it, it can be hard to switch off. That there is a danger of burning out. Right?

MANNING: [laughter] Yes.

Q: Can you tell me about what powering down was like for you at various points in this response?

MANNING: There was only one powering down.

Q: It was just this final powering down?

MANNING: The final powering down. [laughter]

Q: So the first time you come back from a country, you're still working in Atlanta, and so you're still powered up?

MANNING: You never leave. I couldn't fathom setting aside the response. That was 01:16:00not part of my template. I don't know how this would be for others, but you feel--certainly as I did, coming from the Viral Special Pathogens Branch, coming from a close working relationship with Pierre, that--and, you know, you try not to have any illusional ideas about your own value, because we're all expendable and replaceable. But a certain piece of me thinks, and would have thought then, I need to stay in this as deeply as I can, because I think I have something to contribute. I say that in absolute humility, not thinking that I have any right 01:17:00to boss anybody around, but rather that here in this madness, I've got a little bit more knowledge of a certain thing than others have. That doesn't make me an expert, it just makes me the guy who is a little bit sharper about one thing. And that's it, period. The rest of it is like a swirl.

When I got to the spring of 2015, I was pretty exhausted, and I could see the manifestations of that in my work, and I could see that there were certain times I wasn't connecting dots.

Q: Can you give an example?

MANNING: No, I really can't. I'm trying to think. There was something I should be doing that I wasn't doing, either because I hadn't imagined it or because I was just too tired to do it.

Q: Sure.

MANNING: But I don't have any good--and there's nothing I'm concealing. I just had this sense that I'm--it was like, I'm getting tired.

Q: I understand.

MANNING: By the time I was at the end of June, I had made a plan to just take the month of August off and exit back into my branch. Because we're the Viral Special Pathogens Branch, Ebola's our bug, I was aware that one might claim to be exiting the response, but Ebola's still our bug, so how different is life going to be anyway? So I took the month of August off. I just took it off. I told my wife I was leaving, I put my bicycle in the car and put my guitar in the car, put my tent in the car and a cooler and a sleeping bag, and I took off to go mountain biking in Montana and Colorado and Utah. I did, for a month. And I 01:19:00came back and I was okay. I can tell you that if I hadn't, I would probably--I would have--I'm not sure. I would have had grave doubts as to whether I could have continued here.

So I took that month and I came back thinking, I'm unexpectedly fine. I want to work here. I can't wait. And I was absolutely surprised. But I needed to sort of rinse that whole thing out. It's not that it's gone away, but I was--you know, I heard [Thomas R.] Frieden speak about burnout in a meeting, in a gathering, I don't know, a month and a half ago. And I had the experience that I was probably one of the few people that was actually burning out. No. [laughter] I think our numbers were higher than that. So I'm not proud of the fact that I was just 01:20:00exhausted, that I needed to bail, but, you know, I just did need to stop. I pushed it down for, like, a year and a half, and then I was like, there's nothing left and I'm going to make a mistake if I don't take action.

Q: Right. It's self-aware, so that's good. This is coming around full circle, actually, to the very beginning of the response. I think you said, "No one in Viral Special Pathogens jumps out of their chair because there's a rumor of Ebola going around," right?

MANNING: Yeah, yeah.

Q: And it's when laboratory confirmation happened with this epidemic, and probably others in the past, that there is in fact Ebola that you get on the ground. And you get on the ground fast. You know? It's quick.

MANNING: Yes.

Q: But in situations in West Africa where there's not great surveillance and 01:21:00where laboratory confirmation of things is not going to be as fast as it would be in, say, a developed country, how does that work? Does that have to change somehow?

MANNING: It can. And there's a model for that, actually.

Q: Okay.

MANNING: It will be true that with a zoonotic virus like Ebola that is resident in animals and occasionally spills over into humans, that the point where that spillover occurs is likely to be distant from big cities and laboratories and infrastructure. So there will be some lag in that period with respect to the recognition that the symptoms are different, the recognition that this is something we've not seen before, the need to get a team out there to draw blood, 01:22:00handle the patient or patients, and get that sample transported in good condition back to the point where it can be tested and the results can be interpreted or decided. The question becomes, how can you make that process faster? Certainly the fact of there being an Ebola outbreak in your country--in its aftermath, more people are alert and so more people are going to report. On the infrastructure side of that, the process that was put in place in Uganda after a number of outbreaks of Ebola involves intensifying surveillance and also pre-positioning supplies so that if, like, the PPE [personal protective 01:23:00equipment] and the gloves and the gowns and all, so that if people see a patient come in with compatible symptoms, they know to wear this stuff when touching the patient, and they know also to draw blood. Then there's a system for taking that blood sample in Uganda, boxing it up, putting it on ice, putting it on a bus and sending it to Entebbe for testing, and then there's the lab in-country which does the testing. So there's your package for shortening, to the extent possible, the amount of time. You no longer ship samples across the Atlantic Ocean, you no longer wait until a number of people are becoming sick to send people into the area, because they're already there. You test right away, because even if it's negative, you'll have learned something. That whole model 01:24:00is something which is going to unfold in West Africa, and perhaps even more, with even greater penetration, if indeed the rapid diagnostic testing can be carried out very close to where the suspect cases first appear. The closer you are to where that person is sick, rather than having to wait for the sample to travel down to Freetown or Monrovia or Conakry, the better will be your shot at acting quickly. Anybody will tell you, from Pierre on up to Frieden, that speed is of the essence, and it's especially of the essence in the early days, before this thing gets wound up again. So the model is a good one. It will be in place, and it's being put in place in West Africa now. One of the things we've not seen in this period of time, in this aftermath--we've not seen a recurring--we've not 01:25:00seen cases. I think in some ways we're measuring an outcome, which is something which is not happening, which is somewhat different. It's not so easy to quantify that. But it means that there are systems in place that are intended to be doing a certain thing, and they are doing it. So, hooray for us. I mean, we learned. Very costly, but we learned.

Q: Looking back on the response, is there any area of your response that you think we haven't described in enough detail that you'd like to cover?

MANNING: Can you give me an example? I don't know--

Q: Sure, sure. Maybe we've skipped some of your time in--I guess we haven't--or, you spent some time in Liberia.

MANNING: Mm-hmm.

Q: We haven't really talked about that.

MANNING: No, I was there really briefly, and there was already a good team lead there, and the model seemed to be working quite well. I thought that the Ministry of Health [and Social Welfare] was strongly engaged, and I thought that the Carter Center was strongly engaged. And I didn't see there being a need in Liberia comparable to what there was in Sierra Leone.

Q: Do you remember what month you were in Liberia?

MANNING: Oh, god, that's a tough one.

Q: Sorry. Was it before or after their huge peak?

MANNING: It was after. I think. I don't feel so skilled in commenting upon that. If, in terms of a date--the time I was there--I know Katherine Lyon-Daniel, who was in-country, she went to Sierra Leone--first, I believe, to Liberia, and then 01:27:00onward to Sierra Leone. And so whatever period of time that was, whether that was July, or--what was it? It might have been more like September, October of '14? I'm doubting my own memory on that. Just as a very broad comment, I think I might have mentioned this as an earlier point: the three countries had--they had very different responses with health promotion. Sierra Leone, I think, was the one that arguably had the strongest continuity from team lead to team lead in health promotion and people who stayed, in the case of Kathy, for an extended period. Very exemplary in terms of how one might like to have a--not to mention the NGOs that all came to the table very quickly. Guinea was not that way. 01:28:00Liberia had another kind of understanding of how to go about responses based upon not so many people from the CDC side, but others in-country who were stepping up. So I understand Liberia least well of that, but Jana Telfer would be the one to chat with, because she was over there a couple of times as team lead. John O'Connor as well.

Q: Okay. Good to know. Just looking back, anything else that you'd like to comment on about your part in the response?

MANNING: I hadn't moved far outside of my little cave over in the Viral Special Pathogens Branch prior to this response. So I didn't have much of a sense of how the EOC worked when it was activated. I attended the mandatory introduction to 01:29:00the incident management system and the whole EOC, but it always seemed as if that was a bit of a whole other planet. I was very taken, early on and certainly pretty much throughout, with how people who, I didn't even know who they were, coming up to me and saying, I'd like to work in health promotion and go in-country. I mean, people calling me and just saying this. I was like, are you sure? It wouldn't surprise me if other team leads who sat in positions kind of like mine over the course of the response--I think they would also tell you how 01:30:00extraordinary were the people who stepped up. They weren't, at least from what I have seen in the health promotion team, they weren't adventurers and they weren't posers and they weren't self-aggrandizing. They were sincere, level-headed, practical, get-it-done, step-forward folks who have lives, who have personalities, who have families, who have--whatever. I never failed to be humbled by that willingness--I mean, I see that myself, but I don't expect for it to be showing up in other people months into the response. It was just unimaginable. I'm not a cynic, but I just thought, how is it that we can 01:31:00populate so many damn people into a dangerous response in countries with a history of political instability? And yet people keep showing up on our doorstep saying, I want to go. And I continue to be blown away by how generous and willing and good-hearted people have been, from top to bottom. There's nothing short of a real humanitarian aspiration that's going to get you out of your chair and onto a plane to West Africa. You don't undertake to do that if you have other goals in life--this is an expression of how you live. And I thought, from what I saw day in, day out, that people were really willing to find their place. We tried to give them a shot at getting into that place and excelling in 01:32:00that place and supporting them while they were there and expressing, to the extent that we could, our valuation of them as people. Because I think at the end of the day, you might have staff, you might have employees, you might have those who work underneath you, and you might have those who you supervise, but in the end it's a lot of one-on-one. People are going there and they're not comfortable for some of it, they're in danger for some of it, some things happen which are quite frightening. It's not a war, but it's a protracted and difficult engagement. And people were really willing to step up, and oh, yeah, okay, so we pay them, and so they get to fly to another country, but damn it, they were quite solid. That was really striking to me, how much of it there was here. People who make no other--who aren't making pretentious boasts about their 01:33:00skills, just straight-up folks doing good work, and I just admire the shit out of that, to be honest. [laughter]

Q: Well, thank you, Craig, for being here for the second time.

MANNING: Sure.

END