Gregory Armstrong



CRAWFORD: Today is Friday, March 16, 2018. This is Hana Crawford for the Global Polio Eradication Initiative [GPEI] History Project, and I'm with Dr. Gregory [L.] Armstrong [MD] in the broadcast department of the U.S. [United States] Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia. We've had one pre-interview session in prep for today. Todd [F.] Jordan is our videographer. Usually, I provide a little bit contextual information, but I'm going to have you do that, if that's OK.

ARMSTRONG: Sure. The main reason I'm here is that between early 2012 and mid-2015, I was the incident manager for polio eradication in the Emergency Operations Center [EOC at CDC, Atlanta]. In other words, I was the person who was running the operation there during that time period.

CRAWFORD: Great. Let's see. Also, we'd like to get a statement of verbal consent. Do I have your permission to conduct and record this interview?

ARMSTRONG: Yes, of course.

CRAWFORD: Thank you. To open it up, we usually start--we always start--at the beginning in oral histories. If you would, please state your name, and share a bit about your early life. Begin wherever you'd like.

ARMSTRONG: Sure, so [I'm] Greg Armstrong. I am currently still at CDC, running a program called the Advanced Molecular Detection [AMD] program. I don't know, I grew up mostly in the eastern U.S. I moved around a lot when I was a kid. Ended up at CDC in 1997, doing a fellowship, and ended up staying since then.

CRAWFORD: OK. Could you talk a little bit about where you grew up, some of the different places you lived, and share a little bit about your family background?

ARMSTRONG: Sure. I came from a family of two brothers, one sister. I was born in 00:02:00Michigan. My father was a graduate student at the time and ended up down in Virginia for a while, then in Illinois for a year, and Massachusetts for a while, Connecticut. When I went to college, they ended up going out to Arizona, and, in fact, the largest part of my family now is out in Arizona.

CRAWFORD: What was your father's area of study?

ARMSTRONG: He was an engineer.

CRAWFORD: OK. Let's see. I'm interested in a bit about your early career, then what brought you into polio.

ARMSTRONG: Yeah. Actually, [going] back to college, where I was actually studying biology, and actually I had a minor in biophysics and was actually very 00:03:00intent on going to medical school. But at the same time, I had never been out of the United States during that time, except briefly across the border into Canada. [I] was actually--had been--very intrigued, since I was in elementary school, by the Peace Corps. Decided in college that that's what I wanted to do after college.

I ended up going overseas to Togo to teach science for a couple of years before coming back and going to medical school. That actually first got me very interested in the issue of international development and international health. Then after that I came back. I did medical school, did a traditional residency, did a fellowship in infectious diseases, and it was a result of that that actually I ended up back at CDC on a project, a research project, that I was doing.

CRAWFORD: Could you give a few details and examples of your time in Togo?

ARMSTRONG: Well, so, I was a Peace Corps volunteer for two years, I was teaching science. Actually, I'd been sent there to teach, or sent to the school, which was in the northern part of the country in the savannah, and one of them--I mean Togo's a small country, but it's one of the more remote parts of a small country. There was actually a lack of teachers there for the natural sciences, as well: biology, and geology, and so forth. I ended up having to teach that, as well. I very much enjoyed it. I'd taken French in high school and a little bit in college, but you know, you never really learn a language that way. This was actually a real opportunity for me to cement that and to develop fluency in French. But, more than that, it was, as I said, this was the first time I'd 00:05:00spent any time overseas.

I would like to say I was an effective teacher. I probably wasn't. [Laughs] Physics and math were the most difficult subjects for the students. I was relatively inexperienced as a teacher. I think I left something positive there, but, let me tell you from my perspective, I also gained quite a lot from the experience.

CRAWFORD: Are there stories that stand out to you about your students?

ARMSTRONG: There's no single story that stands out, although I do remember some 00:06:00amusing anecdote that sort of brought something home once when I was there early on. The town I was on was near a river. Back in the old days, like a hundred years before, the people of the area would sacrifice a light-colored child into the river every year, to keep the spirit of the river happy. The colonizers, first from Germany and then from France, put an end to that. But people to this day remain suspicious about that. In fact, several years before I was there, some white tourists had been attacked by a crocodile in the river. [Laughs] And so, I was visited one night by a couple of my students who were deeply concerned 00:07:00that they'd seen me walking down by the river, and they told me I should never do that, that they knew that I didn't believe it, but they'd seen things that they just couldn't explain, and they wanted to make sure that I wasn't going to walk down by the river. [Laughs]

CRAWFORD: Do you remember what you thought in response to that?

ARMSTRONG: Well, I was both kind of amused, and also kind of touched that they were that concerned about my security.

CRAWFORD: After that, you eventually went to medical school. How much time elapsed after the Peace Corps, before you--

ARMSTRONG: Oh, I just went right into medical school after coming back. It was actually quite a transition, quite an abrupt transition. Yeah. But I was very much ready for it, just very excited to get back and to sort of start moving my 00:08:00career along again.

CRAWFORD: Was there any area of medicine that you intended to focus on?

ARMSTRONG: Well, I was always interested in infectious diseases.

CRAWFORD: Could you talk about entering into that program of study, that path?

ARMSTRONG: Well, I took a fairly traditional course through medical school, did actually do some time overseas in South America and in Africa. In fact, [I] took a little bit of time off to do some work in Africa, so I ended up graduating a little bit after the class that I started with. But then [I] went on to a residency in Philadelphia at the hospital at the University of Pennsylvania. I had met my wife, who also works here at CDC. I'd met her in medical school, but 00:09:00she was also doing a PhD at the time, so she was a little bit behind me. After I finished residency, I worked for a couple of years. She came to Philadelphia and joined me. She was also in the same residency program. Then after that, we both went on and did infectious disease fellowships down in the Washington, DC area.

CRAWFORD: How did you move toward polio? What led you toward polio?

ARMSTRONG: Yeah, so I started here at CDC about 1997 and worked in a few areas. I started out in the hepatitis division [Viral Hepatitis Division (VHD), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC] and actually enjoyed it very much. We had a very strong group there, and we actually got a lot of, what I think, was important work done there--work that, in fact, 00:10:00still has implications today.

But eventually, after I think I was there for six years, [I] moved onto [the] refugee health branch [Immigrant, Refugee, and Migrant Health (IRMH) Branch, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases] here at CDC. I actually was increasingly interested in working overseas again and doing something that was a little bit more programmatic, a little bit more involved with implementing programs. In this case, we were working with refugees who were coming to the U.S. to address infectious diseases issues among them--in the refugee camps that they were staying in.

Then, after that, I was recruited into something called the Division of Viral Diseases [(DVD), National Center for Immunization an Respiratory Diseases (NCIRD), CDC], which is a program, or it's a branch at CDC that covers mostly 00:11:00vaccine-preventable viral diseases: measles, mumps, rubella, varicella, chicken pox, CMV [cytomegalovirus], viral gastroenteritis, including rotavirus, norovirus, and viral respiratory diseases. It was a fairly new branch. This was a short period after the large reorganization here at CDC, and after any sort of reorganization, there's a lot of work that needs to get done to get things moving back in order again. But it was a very large branch with a very diverse set of subject matter. But one of the areas that we covered was actually polio 00:12:00on the domestic side, believe it or not.

At CDC, the Global Polio Eradication Initiative is in one of CDC's centers, the [National] Center for Global [Health]. But the laboratory that covers that is part of the Polio and Picornavirus Laboratory Branch [Division of Viral Diseases (DVD), National Center for Immunization and Respiratory Diseases (NCIRD)], which is in the division that I was in, which is in a separate center at CDC. But the two were working closely together and still worked very closely together. A very small part of what my branch did was polio on the domestic side, which was--it was mostly a matter of maintaining policy regarding polio vaccination in the U.S., although there was one polio case in Minnesota while I was there. But at 00:13:00division meetings, I would oftentimes chat with Olen [M.] Kew [PhD] and Mark [A.] Pallansch [PhD], who were at the top of the polio and picornavirus branch, about what was going on in polio, because I'd been observing it for a long time.

I guess it was about the time I came to CDC, I was starting to hear more and more about the polio eradication program and to follow what was going on with that so that was late 1990s.

Around that time there was quite a bit of optimism, and they were making quite a lot of progress. The Americas had already become essentially polio-free. We didn't realize it then, but they were about to see the last case of one of the three types of polio, type 2 [wild] poliovirus. A lot of people at CDC were 00:14:00volunteering as part of the STOP program, the Stop Transmission of Polio program, to go overseas for three or four months to work on polio eradication. [I] actually had considered doing that, although it was hard for me to get away for that long a period of time, so I ended up not doing that.

But as the 2000s wore on, that rapid progress and the optimism started to lose steam, particularly when they got down to the remaining four countries: India, Pakistan, Afghanistan, and Nigeria. The biggest challenge that I could see at that time was what we were seeing in India, which was that kids were getting vaccinated with the oral polio vaccine [OPV] repeatedly, sometimes a dozen 00:15:00times, and then getting polio.

The vaccine was not working nearly as well as it had in the Americas or in the other places where they'd managed to eradicate or eliminate polio. There were basically two questions. One was, "Is it even feasible to eradicate polio if kids are getting polio after twelve doses of vaccine?" And number two is that clearly, there are also some intense efforts to eradicate polio in India. There were still real problems with the program itself, in terms of being able to reach enough kids. There was this technical question, "Can it even work in a place like India?" And number two, the more programmatic issue, "Can they 00:16:00actually manage the program well enough to get a program that's effective enough to be able to interrupt polio transmission?"

I guess as the 2000s wore on, I was becoming increasingly skeptical about this. This was a very expensive program. If it wasn't going to work, should we be investing as much as we are in it? Yeah. Go ahead.

CRAWFORD: Were you thinking at all about circulating viruses?

ARMSTRONG: Circulating vaccine-derived--

CRAWFORD: At that time?

ARMSTRONG: --polioviruses [cVDPVs]?

CRAWFORD: [Yes.]

ARMSTRONG: I was definitely well aware of those. I mean, they're, the circulating type we didn't really see in the U.S. But we did see vaccine-derived polioviruses where a child was immunized, for example, and gave the vaccine 00:17:00virus to a parent, for example. Or in that case of polio that occurred while I was in the Division of Viral Diseases that occurred in Minnesota, it was a child who had been vaccinated in the 1990s, and they didn't realize it at the time, but the child's mother had a relatively mild immune deficiency, one that wasn't recognized at the time. He passed the virus on to her, and she became chronically infected. But [she] didn't show any signs until I think it was ten or twelve years after she was presumably infected, at which time she developed a severe illness, including paralysis, and died from the illness. We're very well aware of--or I was very well aware of--those viruses. I'd certainly known about 00:18:00circulating vaccine-derived polio viruses, but not as much as I was going to learn later on.

CRAWFORD: Did that figure in at all to this--

ARMSTRONG: Pessimism?

CRAWFORD: Yeah.

ARMSTRONG: [Laughs] It did a little, although I think I felt that there's a technical solution to that. which is, oddly enough, more vaccine. But that seemed like the more minor problem. The real problem was that they've been trying for a long time to stop polio transmission in these four countries, and they hadn't been. In fact, they'd had several setbacks, especially in Africa. I mean it got out of control in Nigeria one year and spread as far east, I think, 00:19:00as Somalia, and as far west as Senegal. The setbacks, in addition to lack of progress, were also big, I think, sources of pessimism.

CRAWFORD: Why would you agree to work on polio eradication?

ARMSTRONG: Yeah, so like I said, I was following this from a distance but talking--you know, I was running regularly into Mark and Olen and getting updates from them and following what was going on. I knew that the [Bill & Melinda] Gates Foundation, and [William H.] Bill Gates [III.], in particular, had also been quite skeptical about this, but had come around to feeling that this really was a very important public health initiative that needed to be completed. I think it was at his insistence, although I don't know the history 00:20:00of this real well.

But I believe it was at his insistence that WHO [World Health Organization] appointed an Independent Monitoring Board [IMB] to provide an independent assessment of progress towards polio eradication. This struck me, first off, as a very much-needed step.

Another reason for the pessimism is that we had been hearing for years these very positive assessments of progress in the program, and repeatedly, time after time, seeing setbacks and lack of progress. To me, it did seem to make a lot of sense that you would bring in an outside group, one that would be able to 00:21:00frankly criticize the program; also, [the outside group would be] for donors out there, to give them an assurance that there was a source of an assessment that they could go to to get a less-biased assessment of where the program was on the road towards eradication. The IMB, the Independent Monitoring Board, had started meeting and started getting to know the program, and I wasn't following their reports, although later on, I went back and you could sort of see out of the first two of these, for example, that they were actually very quickly getting up to speed on things.

I think it was December of 2011, I was at a meeting, and I don't remember what 00:22:00the meeting was, but I just by chance sat next to Eric [E.] Mast [MD, MPH]. Eric and I had worked together back when I was in the hepatitis division at CDC, and he had been, for several years, the associate director for science in the Global Immunization Division [GID]. I took the opportunity to get caught up with him, and he said, "Have you seen the IMB report?" He said, "It's very critical.

It very clearly said that the program is not on track to eradicate polio, and that if it is going to complete this job, it is going to need to scale up its resources. All of the partners right now are reassessing what they're doing, and here at CDC, we're going to go ahead and move the polio program to the Emergency 00:23:00Operations Center. Dr. [Thomas R.] Frieden [MD, MPH] is going to be playing a much more day-to-day role in the program, and we're going to bring in new people and scale this up."

It was when he told me that for the first time, I said to myself, "This can work now." I mean, "This is what they needed." You know, watching it for years doing what looked like was doing the same thing over and over again and not working, it seemed like this was the way to change that, to actually turn the narrative around.

The other thing that had happened was that at that point in time, it was 00:24:00becoming increasingly clear that India had actually interrupted polio transmission. The last case had been in January of 2011. You know, it always takes some time before you start to get some confidence in when you stop seeing cases, that you've actually stopped transmission. But what had happened was that the program, several years earlier, had decided to go back and take a harder look at the vaccines that they were using. One of the mistakes that I think the polio eradication program made early on was inadequate investment.

[INTERRUPTION]

CRAWFORD: You were saying that one of the mistakes that the polio program had made--

ARMSTRONG: Yeah, so one of the mistakes that, in my opinion, the polio eradication program made early on was not to invest enough in research. In fact, 00:25:00there were people in the program who are, from what I've heard, actively hostile to this idea that they said, "If we still need to do research here, then we shouldn't be doing this. We should know exactly what we need to do."

That's a mistake in any public health program, especially in one that's going to be going on for a long time. Up until the end, there's going to be a need for innovation. In fact, it also bothered me early on after I started as the incident manager in polio. I was meeting with somebody from one of the other partners who was talking about what needed to get done in Nigeria, and I mentioned that we really needed to push innovation to figure out what it's going 00:26:00to take in a Nigerian context to get this done. They said, "No, we know exactly what needs to get done. We just need to do it; we just need to make sure that they do it." And fortunately, the program in Nigeria didn't listen to that, and in fact, innovation was a key part of the success there.

But getting back to the polio program, one of the things that the people here at CDC became convinced of relatively early on was that they--we--needed to go back and take a look at the vaccine again. The vaccine, the oral polio vaccine, had been invented back in the late 1950s, early 1960s. It was originally three different formulations. There are three different polio types: Type 1, 2, and 3. But very soon after that, they figured out how pharmacologically to mix all 00:27:00those together, and it's not just a matter of mixing them together. You've got to get them in certain proportions, and one of the reasons, for example, is that the type 2 vaccine component tends to outcompete all of the others. You have to put less of that in the vaccine, for example.

But those monovalent vaccines--the type 1 vaccine or the type 3 vaccine--those hadn't been used since just after the poliovirus [vaccines] had been invented. The group at CDC had become convinced that that type 2 vaccine was interfering with the other two and that we really needed to try separating the three components out again and giving those separately if we're going to interrupt type 1 and type 3 [wild polioviruses].

CRAWFORD: Could you explain, tell the story of, how they discovered that type 2 00:28:00[vaccine virus] competed? I also wonder about your opinion, whether or not that could have been determined earlier?

ARMSTRONG: Again, I do think that we could have determined earlier that the separate components--that using the type 1 by itself would be more effective against type 1 [wild] poliovirus than using it as part of the trivalent vaccine along with the other two. That was just a matter of separating those out into separate vaccines, and then doing the appropriate clinical trials to make sure that they're safe and effective.

Again, there was resistance within the program to doing that sort of research. It wasn't complete resistance. It broke down before long, and they were 00:29:00eventually able to do those trials. But, you know, actually, that was technological advance. Just separating out the vaccine into its three components is a big part of what made it possible to stop [the] transmission of poliovirus in India.

But getting back to why this happens, this is a--and keep in mind I'm an epidemiologist; I'm not a virologist. But in lay terms, back when the poliovirus [vaccine], the oral poliovirus [vaccine], was being developed, vaccinology was still relatively in its infancy. The molecular tools for looking at the virus 00:30:00just didn't exist then. In order to develop the oral polio vaccine, they simply took the wild-type virus--one from a child who developed polio--and put that through tissue culture and on a certain type of cell line for a number of passages.

Then, they would try the vaccine, or the potential vaccine, in primates to see if it caused paralysis. If it did, then they would go back, and they would passage it a dozen more times, and if it still wasn't attenuated, if it still didn't not cause paralysis, they would maybe passage it on a different cell line 00:31:00for a while. They would passage it through these cell lines until it lost its ability to cause paralysis.

Now, the three different types of [wild] poliovirus are not the same. With type 1 poliovirus, if you're infected with it as a child, you have about a one-in-two-hundred chance of developing paralysis. The other 199 kids who get this, some of them probably have no symptoms at all. Some might have a fever; some might have fever and a headache; some might even have a fever, headache, and a stiff neck. But they don't have symptoms that are consistent with paralysis.

In fact, my uncle had polio. He was thirteen at the time, and my father 00:32:00developed an illness consistent with this. He had--and we'll never know if that's what it was or not--but he had a fever and headache and was out of school for a little bit. But [he] recovered. A short time after that, his brother got sick and getting out of the bed in the morning, he fell on the floor and couldn't get back up, which is a big deal. He was actually quite a talented gymnast at the time. Never walked again after that. It's quite likely, my dad thinks--and I think he's right--that he was infected with the virus first.

But at any rate, getting back to this, the type 1 poliovirus causes paralysis in 00:33:00about one in two hundred; the type 2, about one in two thousand; the type 3, maybe one in a thousand. But the type 2, they called it "naturally attenuated," because it caused paralysis relatively rarely among people who were infected with it. When they passaged it and culture, they didn't have to put it through very many passages in order to attenuate it. But as a result of that, they also didn't attenuate its ability to transmit easily between humans.

When you compare that ability with the other two vaccine virus components, those don't grow nearly as quickly in the human intestine. When somebody gets the trivalent vaccine [tOPV], the type 2 virus just goes wild and overwhelms the 00:34:00other two types. What happens quite often--in fact, I think it's most of the time--is with the first dose, the child will actually shed the type 2 virus and not the other two. Then with some luck, the child will develop immunity to that, and with the second dose, that will give the type 1 and the type 3 a chance to grow and to induce the immunity there. The type 2 just spreads much more easily in populations than the other two do. It's probably also why it was so relatively easy to eradicate the last virus. The last type 2, you know, wild-type 2 virus, that we saw was in 1999.

CRAWFORD: Could that have been addressed earlier?

ARMSTRONG: Yeah. I think if the program had been more open to research and had been actually actively trying to identify areas where research is needed, this is something that they would have honed in on earlier, and [they] would have actually invested in looking at monovalent vaccines earlier than they had. Having those available earlier on would have accelerated the elimination in India, for example.

CRAWFORD: OK. In 2012, December 2011, Dr. Tom Frieden activated the EOC.

ARMSTRONG: Yeah.

CRAWFORD: That came months before, six months before [the] WHA [World Health Assembly] decided, declared a global health emergency [Public Health Emergency 00:36:00of International Concern, PHEIC].

ARMSTRONG: Yeah.

CRAWFORD: I wonder about where you were in December of 2011. You had already begun talking about Eric Mast, but what happened from there?

ARMSTRONG: Yeah, so I ran into Eric Mast, and he had told me that the IMB had come out with this very critical report, that the whole partnership was scaling up and looking at what they could do, and the CDC was scaling up its own program and moving it into the Emergency Operations Center. He thought about it for a minute, and he said, "You know, is there any chance you'd be interested in this?" I said, "You know, this sounds like a great opportunity. Yeah, I have to figure out if I've got time to take away from my regular job to do this or not." He said, "Well, let me talk to some people and get back to you."

They contacted me--I forget how long after that--but asked me if I would be interested in coming over and being the deputy incident manager, that they were already planning to formally--actually, they'd already formally activated the EOC in December, but they were planning on moving everything that they could over there in early January. [Robert W.] Robb Linkins [PhD, MPH], the branch chief of the polio branch [Vaccine Preventable Disease Eradication and Elimination Branch], was going to be managing it, but had quite a lot on his hands, because he also had quite a lot to do with his regular job. [He] needed somebody to do this.

I readily agreed to this. At that point, Mark Pallansch had become the division 00:38:00director of the division that I was in, and so he was very supportive of this. I initially went over there to help the program get started.

Actually, let me back up a second. When they asked me about this, if I'd be interested in coming over to be the deputy incident manager, I wasn't sure if I had time, but this was a potentially very interesting opportunity, and potentially an opportunity to contribute to this program at a critical time. But they told me that I would need to do this for three to four months. It was going 00:39:00to be difficult for me to get away at that time for that much time. This wasn't that long after the pandemic, the 2009-2010 influenza pandemic. I had actually been pulled into the Emergency Operations Center three times for that, and I forget how many months I'd spent there, assisting in three different roles. But it's very hard, when you've got a large group like I was managing, to go away for that period of time. You have problems just start to build up, and it always takes a lot to get things back under control again when you get back. In some ways, it's not fair to the people who you have to leave behind to do this for 00:40:00too often. It was actually at that time, after thinking about it a lot, I approached them and said, "You know, it'd be difficult for me to do this for three to four months, but I could do it for a couple of years."

[Laughs] They said, "Well, how will that work?" I said, "Well, you'll have to take me as an employee, and I don't know how long we'll be in the EOC--a year, maybe year and a half. But then I can help that transition after that." But I have some unique skills at CDC, and it's--yeah, I was confident I'd be able to find another position. They were kind of taken aback by this and said, "We'll have to get back to you." [Laughs]

They came back, and they said, "Yeah, we can do this, but we just need to make 00:41:00sure you're going to actually find another job when this is done." I said, "Yeah, I'll look forward to it." I approached Mark and told him that I was--you know, I'd been talking with him--that I was thinking of doing this and told him that I thought this was probably the best for both groups, anyway. It would give me a chance to actually get into the polio program in a much deeper way. But also, it would be fairer for the group that I was leaving behind to have an opportunity to recruit somebody new. We'd actually gone through the--I felt that the time I was leaving was actually probably a good time to leave anyway, just because we'd finished the reorganization and things were running relatively smoothly.

I went over there, went over to the polio program as the deputy [incident manager] at first, and worked quite closely with Robb Linkins, who was the incident manager at the time. It worked quite well. It gave me a real chance to meet with people and to problem solve. Any time you scale something up like that, there's always a million problems that come up, so it's nice for--I think Robb felt it was nice to have somebody who he could detail to actually handle something and take care of it. I could also cover for Robb while he was out of the country, because he still had a lot of travel, especially related to his day job. But when it came time for him to move on, he was--again, it's a stress on 00:43:00your group, if you have a large group, to be away from it for a while. He had a lot going on at that time. When it got time for him to go back, he and Rebecca [Martin, PhD] and, actually, through Tom Frieden, asked me if I would stay or move up to the incident manager position. That's how I ended up there.

CRAWFORD: You just talked about problem solving.

ARMSTRONG: Yeah.

CRAWFORD: --like working with Robb Linkins as [his] deputy to begin implementing the scale-up?

ARMSTRONG: Yeah.

CRAWFORD: Could you talk about some of the problem solving that you did, as well as the resources that became available when Dr. Frieden activated EOC?

ARMSTRONG: Yeah, so that second part's a little bit easier. When we move into 00:44:00the EOC, it does a number of things. First off, we're working very closely with Dr. Frieden. We're meeting with him weekly, initially. In fact, we're meeting with him at least every other week up until the Ebola outbreak hit, at which point he was quite busy with that and we were meeting with him less frequently. But it increased the profile. It gets us an opportunity to bring people in on a temporary basis from throughout the agency, which is a real opportunity. There's, you know-- CDC tends to attract people who like contributing to big things like this, to big public health initiatives. It gives us--it makes it a lot easier to cut through the usual government bureaucracy, so we can--if we 00:45:00need to travel overseas, we can do that as quickly as we need, essentially.

We don't have to put in our travel requests two months in advance. If we need to procure something, it makes it a bit easier. There are resources in the EOC, so, for example, there's a group called "situation analysis" or "[situational] awareness," which does a lot of analysis, can do a lot of analysis and mapping for us. Mapping was actually quite useful because of the various geographies that we were working in. The--

CRAWFORD: I would love to come back to that. Yeah.

ARMSTRONG: --the need to communicate, to communicate what was going on in the program.

CRAWFORD: Problem solving?

ARMSTRONG: Problem solving? So, it's mostly a lot of small things that I quite 00:46:00honestly have forgotten. But it's the sort of things--we're starting with a certain organization, and then we're scaling up to something that's larger and very quickly outgrowing the original organization, so we've got to reorganize things. We've got to set up new groups, figure out what makes sense, who's going to be in charge, how the whole reporting is going to go. Figuring out what we need to keep track of that's actually going to help us and not just add to unnecessary paperwork.

What else? I can tell you many [a] time, I've been in the Emergency Operations 00:47:00Center, CDC's Emergency Operation Center, before it even existed. [Laughs] I mean the first one that we set up was during anthrax. We basically just took one of the auditoriums that had a flat-level floor and took all this heating out and moved in a bunch of desks and cubicle equipment and computer equipment and so forth. That was the first EOC. I was actually quite involved in the anthrax investigations and SARS [severe acute respiratory syndrome] and the pandemic. In each of these, especially in the early scale up, there's always a lot of chaos.

In addition to these organizational issues, there's issues about what sort of meetings we need in order to stay coordinated, but not so many meetings that we 00:48:00can't get work done. All these questions about communications and difficulty with communications--how do we, you know, where do we need field teams? If there are multiple vaccination campaigns going on in French-speaking countries and we've got limited staff who can speak French, how do we prioritize those? So, it's everything from the very bureaucratic to the very technical.

CRAWFORD: Could you tell a few stories about the lessons learned during that period of time?

ARMSTRONG: Early on?

CRAWFORD: [Yes.]

ARMSTRONG: Well, so first off, I think there's always a little bit of chaos early on in any of these large outbreaks I've been involved in. I've actually 00:49:00come to realize that a certain amount of the chaos is probably necessary, because if you try to control it too much from the beginning, you'll end up making the wrong decisions and slowing things down when people need to be moving very quickly. I think one of the lessons learned is that a certain amount of chaos early on is acceptable and maybe even inevitable. But as time goes on, you need to be moving in the right direction; you need to be moving towards being more organized.

CRAWFORD: Could you give an example of how you assessed that?

ARMSTRONG: There's nothing particularly scientific about it. It's just the standard organizational dynamics. You can tell whether people are working 00:50:00effectively together, whether teams are clear [on] what their mission is, and they're clear how to work with the other teams. Clear how--what kind of decisions they need to be making on their own and what kind of decisions they need to be moving up the chain. These are really very basic organizational things, but most organizations aren't set up over five days. You know, a typical emergency response is like that.

CRAWFORD: Drawing from your memories of the EOC early on for polio, could you offer a few examples to illustrate the chaos, or to illustrate the problem solving?

ARMSTRONG: If you'd asked me this three years ago, I could have actually gone on for quite a long time about this. But those things have faded quite a bit. 00:51:00Unfortunately, the things that stick in my mind tend to be the personnel issues, because those are oftentimes the stickiest and the most difficult to resolve. Again, I've seen this in--most of the times I've come to the EOC-- which is that people come there expecting one thing and coming into a job that's not necessarily that. In addition, a big challenge that we have with, or that I've seen over the years in EOC activations, is that in much of CDC, we work in a non-hierarchical way. It tends to be very collaborative, almost academic, 00:52:00although not; there isn't as much independence as you would find at a university, but it is sort of more academic than hierarchical.

But if you need to move quickly, and especially if you need to set up a large organization that moves quickly, you need to be very hierarchical. It needs to be much more of a command-and- control mode than an academic mode. Especially people who've never worked in EOC before, oftentimes have a hard time with that transition, going from being sort of their own boss in a way or providing their own motivation, and being, to a certain degree, in control of their fear of what they're working on, to [being in] a situation, where they are now in a hierarchy 00:53:00where they don't necessarily have a view of the entire expanse of what's going on, where they have to be more respectful of the chain of command than they normally do in their day-to-day work. There is a certain amount of that that happened here, as well, you know: people coming in and with an idea of what they're going to be doing, and it's not necessarily what we need. [Laughs] And, you know, [they are] fitting into an organization, working for somebody who they didn't necessarily sign up to work for. It's those sorts of stresses that stick in my mind that are always sort of the difficult ones that need to be managed.

We didn't know how long we were--we didn't think we were going to be there as 00:54:00long as we were, but we knew we were going to be there for a while. I knew that what we were setting up there was going to need to be able to exist for a while and to be resilient. We couldn't just tell people "shut up and do your work," we have--it's a matter of working with them to figure out what it is that they're after and how we can--you know, again, it's sort of Management 101: figuring out how we can take these people that have got some very useful talent for us and make sure that they're getting what they need while they're accomplishing what we need them to accomplish.

CRAWFORD: What was it like for you to manage that transition for your team?

ARMSTRONG: I [had] just come from reorganizing a branch that, or from inheriting a branch, that had undergone a difficult reorganization. I had some experience 00:55:00in that. [Laughs]

Well, those things sort of stick out in my memory. There's nothing that was particularly traumatic. It was--I don't know if you'd call it routine, but it's the kind of thing that anybody who's done any kind of management has had to deal with.

CRAWFORD: How about tips for going through a difficult reorganization?

ARMSTRONG: Well, so my first tip is don't reorganize unless you have a very clear purpose for it. [Laughs] I don't know if this is the same in the private sector, but in government, any kind of reorganization ends up having repercussions for at least a couple of years. It takes a couple of years for most groups to really get back on their feet again. It's because the people have 00:56:00come in expecting to do something and were recruited by someone and are now suddenly working in a different group than they started out with and working for somebody who they didn't sign up to work for. On top of that, you have an entire branch--or a division, or a center--that's going through that all at once. There [are] always people [who] aren't necessarily unhappy with it, but there will always be some people who are unhappy with it. It takes a while to work that through, for them, to either come to terms with what they're doing or to sort of mold the job into something that they want to do or to find another job. My first piece of advice in government is really, if you're going to reorganize, 00:57:00have a very clear idea of why it's needed, because it's going to be a while before things get back to normal again.

CRAWFORD: All right.

ARMSTRONG: But other than that, I--

CRAWFORD: Other lessons learned.

ARMSTRONG: Yeah.

CRAWFORD: Early on.

ARMSTRONG: Early on, I think--so a certain amount of what we dealt with was unique to what we were doing. We needed to--but you're talking about lessons learned?

CRAWFORD: Lessons learned. I mean, I'm also thinking a bit about Ebola, because you were also involved in the Ebola response a little bit.

ARMSTRONG: I was, although relatively late, and just in the field. They needed somebody who could speak French to go and take over as the lead in Guinea. I 00:58:00wasn't involved in the EOC side of things of Ebola.

I think the biggest thing is to pay close attention to the human part of it, that any organization's biggest resource is its people. It takes a lot of hands-on, a lot of talking with people in order to understand what it is that they need if they are unhappy about the reorganization. You're figuring out what 00:59:00you can do to either make them more effective and more satisfied with what they're doing, or, if need be, to help them find another job.

CRAWFORD: Were there ways--did you find in working in polio in those early days that you had to help people find other jobs?

ARMSTRONG: Fortunately, I don't think we had anybody in the group who actually ended up having to leave. We did have a number of people who came through as volunteers for varying amounts of time who didn't work out. That's a much easier situation, because they're there, to begin with, for a limited period of time, and so we have the option of not extending them. Although sometimes, that leads to a difficult conversation about, you know, why we're not extending them.

Actually, now that I think about it, one of the lessons that we learned early on was in deploying people overseas. We really had to screen them much more closely than we thought we did, initially. For example, we found out that people who claimed that they could speak French fluently, for example, really could not. We really needed to have somebody on staff, and there was actually somebody who was actually quite good at this, who could bring somebody in, make them feel comfortable, and have them speak to them in French and make a frank assessment of what their French-speaking ability was. But also, we just needed to interview 01:01:00them more closely to find out a little bit more about what their skills were and how likely they were going to be [to be] able to work in difficult situations overseas. Most of the places where polio is are not easy places to work if they're in low income countries, sometimes with real security issues. We did have people overseas who could just--one in particular I can think of who just, I think, had underestimated how difficult it was going to be for her to be in Nigeria, and we just had to pull her out.

CRAWFORD: Could you explain why, and what the situation was?

ARMSTRONG: The security situation. Compared with Pakistan or Afghanistan, the 01:02:00security there is easier, at least in Abuja, that capital. But there's still serious problems there.

I remember the first year I was there, for example, the insurgency. Boko Haram blew up a building in the middle of Abuja, the capital city, where our staff were. Our staff were there at the time, in fact. I don't remember if this happened before or after this, we had to bring this person back, but I think she just, being on the ground, she just became, felt increasingly uncomfortable about her own safety. It was our policy in a situation like that that we don't ask questions; we just pull them out.

CRAWFORD: You received a call about this person?

ARMSTRONG: Yeah. I didn't directly. I was supervising the supervisors, and so [it] was somebody else who was in conversation with her. She came to me and let me know what was going on and that she thought that we needed to pull this person out.

CRAWFORD: OK. We've moved through early lessons learned there. At this point, you are the incident manager.

ARMSTRONG: [Yes.]

CRAWFORD: What month did you officially become incident manager in 2012?

ARMSTRONG: It was fairly early. It was February or March, I think. Late February or sometime in March.

CRAWFORD: OK. It was before WHA [World Health Assembly]?

ARMSTRONG: Yeah.

CRAWFORD: OK. Great. Could you talk through that time?

ARMSTRONG: Those early months?

CRAWFORD: Those early months. You've done some problem solving; you have all of 01:04:00these resources. Where do you go from there? What are your priorities?

ARMSTRONG: There was a lot going on in a lot of different places. In the endemic countries--in Nigeria, Afghanistan, and Pakistan--there was a need for us to support what was going on there. We had the largest ability to do something in Nigeria, just because of the situation there. In Pakistan, we tried to do what we could, although it was difficult for us to even get people into Pakistan to be able to do anything. Most of what we did was just to support them remotely. It was the same thing in Afghanistan. We were able to put somebody there, but she was based out of the embassy there. There's a large compound there, where 01:05:00she stayed and worked and had a hard time getting out of that in order to be able to visit with people. Her counterparts who she was working with, fortunately, were able to come in, so they could come in, and she could meet with them on a regular basis there. But it was mostly--of the three endemic countries--was mostly Nigeria [where] we were able to have an impact.

In addition to that, there were countries that had recently had outbreaks, countries that had, at some point in the past, interrupted polio transmission, but had gotten reinfected. At that time, those had all been reinfected from Nigeria, so this was, I believe, Chad. Was it DRC [Democratic Republic of Congo]?

CRAWFORD: Somalia?

ARMSTRONG: That came later. God, I'm forgetting which countries in West Africa now. But there were a small number of countries in West Africa [where] poliovirus, wild poliovirus, had been reintroduced there, and they were stamping it out again. Then, in addition to that, there were a lot of countries, especially across Africa, where we really needed to maintain polio immunity. We needed to have regular vaccination campaigns there to make sure that if a virus did get in there that it didn't spread. We had a lot of staff that were sent out to assist with that.

We also had staff that were assisting with WHO headquarters, helping, for example, with the analysis of data. We were able to provide a certain amount of support from Atlanta with regards to that, putting together a lot of the data to 01:07:00monitor the program, but also to provide donors and other supporters with up-to-date data on what was going on with the [polio eradication] immunization program--also, putting together regular reports for the Independent Monitoring Board.

CRAWFORD: Since you brought up the Independent Monitoring Board and donors, I wonder if you could talk about some of the other partners of the Global Polio Eradication Initiative, and, since we're still within talking about the time period of your first six months, what the kind of landscape was, in terms of the different roles of WHO, UNICEF [formerly, the United Nations Children's Emergency Fund], Rotary International, Gates, CDC.

ARMSTRONG: Sure. First off, we worked with all of them, some more closely [than] 01:08:00others, but we definitely worked with all of them. WHO is the global lead for polio eradication. They are the group that has the teams in the field that are doing most of the work. They've got a lead in Nigeria, for example, and they've got, I forget how many hundreds of staff there who are working on polio. During a vaccination campaign, they all have thousands of people in the field, working for them for a few days at a time, administering polio vaccine. They're really the main implementing partner. They work very closely with UNICEF, which is also a UN agency. But UNICEF is in charge of advocacy and communication, which is critical in polio eradication [by] communicating with communities, letting them 01:09:00know what this polio eradication program is all about, why we come by every few months to give polio drops to their kids; to maintain confidence in vaccination and so forth. That's simplifying what they do, but that's one of the most important aspects of what they do as the lead for communications.

CRAWFORD: What were they working on when you came into the EOC?

ARMSTRONG: They were in all the countries, and they were in lead, in charge of what we call "social mobilization." For example, when a vaccination campaign was going to take place, they would essentially do advertising for it to make sure that people were aware of what was going on and make sure that they were prepared to participate in the vaccination campaign, or to allow their children 01:10:00to participate in it.

CRAWFORD: Were there any major changes in the roles of any of the partners or any particular challenges that are memorable?

ARMSTRONG: Not really. Not during the time that I was there. I have to say, I've seen lots of partnerships over the years. I knew going into this that these were five partners that had been working together for a very long period of time. In that sort of situation, you always see tensions, and actually, what I was shocked by was how few tensions there were--how well the partners were actually working together--and I could say that sincerely. I mean there were always squabbles about one thing or another, as there are in any family, but nothing 01:11:00that ever degenerated into a serious--nothing that ever got out of control.

CRAWFORD: Any lessons learned from working in partnership?

ARMSTRONG: Communication is the big thing. There's a real advantage, I've found, to having people detailed to other partners. CDC does this a lot, so we've got a number of people detailed to the World Health Organization. We had at least one while I was there detailed to UNICEF. We didn't have anybody detailed to the Gates Foundation, but several of the people at the Gates Foundation had come from CDC, so we knew them quite well. Actually, when I started there, WHO had 01:12:00detailed one of their people to the Emergency Operations Center. One of the people in UNICEF had come from CDC. Those kinds of connections, I think, are key. The partnership works better when the partners understand each other and when they have worked side by side with one another. So, I think that's the key, is that kind of communication.

CRAWFORD: I'll ask you a little more for, just to finish out the list of partners. You spoke about WHO, so you worked with them in a technical capacity.

ARMSTRONG: Yeah.

CRAWFORD: UNICEF and social mobilization and communications.

ARMSTRONG: Yeah.

CRAWFORD: What about Rotary International?

ARMSTRONG: Yeah, so Rotary has been in this from the beginning. In fact, from before the beginning, they had this idea, back in, I want to say it was the '70s, it was a long time ago, to stop the transmission of polio in the Philippines. That ended up working and being kind of a launching pad for global polio eradication. You know, [Stephen L.] Steve Cochi [MD, MPH] knows this history much better than I do.

But they, and CDC and WHO, got together in the 1980s and decided to make a push for global polio eradication based on this experience in the Philippines, based on experience in Brazil. Rotary has been involved in polio eradication since 01:14:00then. Since 1987. Since the World Health Assembly declaration, they've been through good times and bad times and have stuck with it the entire period. I mean, the one thing I'll say about Rotary is that their persistence in this has been extremely useful--just the fact that they've been able to stick with this through the bad times.

The other thing that's really valuable about the Rotary partnership is their connections in country. They've got connections to Pakistan and Nigeria and in dozens and dozens of other countries that we've had to work in over the years. Having those connections has been very useful in terms of advocating for the 01:15:00program, in terms of, you know, increasing its visibility and getting collaboration from the host government, because these Rotarians are oftentimes quite well connected. If they're not quite well connected, they know how to get things done. Having that large global network from Rotary has been a big asset.

CRAWFORD: Do you recall in your time, especially--yeah, so 2012 to 2015, do you recall any stories, incidents, examples of Rotary interfacing with your role as incident manager?

ARMSTRONG: Not directly. They--I mean, we met with them periodically and would 01:16:00help them out occasionally when they were doing some advocacy. They wanted somebody to come from CDC and talk about the current situation.

[INTERRUPTION]

ARMSTRONG: The question was how we interfaced with Rotary?

CRAWFORD: [Yes.]

ARMSTRONG: We would meet with Rotary on a regular basis to--first of all, there [were] partnership meetings where they were participating in it. But we would also meet them occasionally to get each other up to date on what we were doing. They would oftentimes invite us to give a talk at meetings of Rotarians about what was going on with polio eradication. They always liked to have somebody from CDC come and give an update on what's going on in the latest happenings in the polio eradication program.

CRAWFORD: How about Gates? Did you work closely with Gates? Bill & Melinda Gates [Foundation]?

ARMSTRONG: Yeah, actually more closely with Gates, because when they came onboard in the late, it was late 2000s, they brought in some new ideas, both on the technical side and also on the fundraising side, which was important because the program was a billion-dollar-per-year program at that point. But the staff there had a lot of technical expertise, and some of the staff over there had real expertise in polio eradication.

The person they sent to Nigeria, Michael Galway, had been in India for many years during the polio eradication program there. [He] was able to take some of 01:18:00the lessons that they learned from polio eradication there and work it in India. But, in addition to that, our ability to move around in Nigeria was very restricted, because we were U.S. government employees and because the security situation was difficult there. They actually had--it was a little bit easier for Michael to move around [as a Canadian citizen], for example. He spent quite a bit of time up in Kano [Nigeria], which was difficult for us to get to. Also, he was able to take advantage of the fact that Africa's richest billionaire happens to live in Kano, and so Bill Gates was able to make a connection with him [the billionaire] and get him engaged and helping to advocate with the government locally to get them to fix some problems in the polio program.

In addition to that, Gates is also able to move very quickly in certain things. 01:19:00For example, they're the ones who'd proposed initially, I believe, setting up an emergency operations center in Abuja, the capital in Nigeria--offered to fund it, and so they just went out and rented space in a building right across the street from the health department. When that fell through at the last minute, they just bought a different building and set up the EOC there. They can move much more quickly than the U.S. government can in a lot of ways. In addition to that, like I said, a number of the people who are over at the Gates Foundation working on polio are people who had come from CDC. We have a very strong working 01:20:00relationship from them anyway, from the beginning.

CRAWFORD: Returning back to the chronology. We're probably still looking at the time period around February, like March to summer 2012.

ARMSTRONG: Yeah.

CRAWFORD: I think we should--I've checked the time, we have about half an hour left--

ARMSTRONG: OK.

CRAWFORD: --which isn't a ton of time. Maybe you'd be open to a second interview at some point?

ARMSTRONG: OK. [Laughs]

CRAWFORD: But Pakistan and Nigeria, I think those are important, and in STOP, Nigeria's Stop Transmission of Polio program, too.

ARMSTRONG: Yeah.

CRAWFORD: I'll open that up.

ARMSTRONG: Nigeria. Back in early 2012, we were scratching our heads as to what we could do in Nigeria, how we could improve on the performance of the program 01:21:00there. One thing we did was to send Frank [J.] Mahoney [MD] there. Frank was a very experienced epidemiologist. He had come to CDC, I think, back in the early '90s, and had worked overseas in a number of places--Egypt, Iraq, Pakistan--and had a reputation for being able to get things done in the field. When we proposed going to Nigeria, initially just temporarily, I didn't think he would accept. But he was actually quite eager to do it. He saw it, I think, as a problem that needed to be fixed.

We got him on the ground there, fairly early on and started to brainstorm about 01:22:00what we could do.

Now, when we met with Tom Frieden early on about this, his initial idea was we need to learn from the India experience. And one of the key things that made the program work in India was getting a lot of physicians in India to work in northern India where the problems were. He [Frieden] brought this up at a meeting, and he said, "Why don't we do something like this in Nigeria? You get one hundred physicians and get them deployed up in the north and have them focus on polio." I remember being in a meeting, and everybody around me was shaking 01:23:00their heads yes, and I was wondering, "How were we going to do this?" [Laughs] Yeah, I was fairly new, so I thought they must have known something I didn't know.

Because what I knew was that there's a big brain drain in Nigeria. There's not a whole lot of physicians there. There's a tremendous amount of talent in Nigeria, but a lot of that talent leaves. In addition to that, a lot of those physicians were trained in the south, and are from the south, and would have a difficult time working in the north at that time--you know, when things were very insecure.

I remember getting out of the room and asking people, "I don't get it. How are we going to do this?" and they said, "We're never going to do this." [Laughs]

At any rate, I went back to the team and talked to them about this, and so one of the lessons early on that I learned was that we need to be much more frank 01:24:00with Tom Frieden. Actually, what I'd found was that he very much likes that frankness. He doesn't want you to be negative, but if you think something isn't a good idea, he wants to hear that, and he wants to hear why it's not a good idea. He wants to hear you defend that.

I remember over the next several weeks, we went back and forth with a number of ideas about this. It was about that time that Frank came back from Nigeria for a short period. He said, "Let's take advantage of the FETP [Field Epidemiology Training Program] program there."

CDC has a number of programs around the world called the Field Epidemiology Training Programs that train staff from the country, from the host country, in 01:25:00practical epidemiology, and how you apply epidemiology to prevent disease, investigate outbreaks, so forth. This is actually, oddly enough, very different from what a lot of them learn at university. When they study epidemiology, it tends to be very academic about p-values--

CDC has found these programs to be very valuable and had set one up in Nigeria. They'd recently scaled it up, I think, to sixty people per year from, like, twelve people per year.

CRAWFORD: Do you know why, what the occasion was for that?

ARMSTRONG: No, it just felt that it was very effective and that there was a big need for this, and they wanted to scale this up. At any rate, Frank said, "Look, we've got already a group of people who have graduated from this program, who are probably being underutilized at what they're doing. We could hire some of 01:26:00them on."

Additionally, the FETP program was very eager to work with us. They take these people who are normally working already in the Ministry of Health and take them out of their jobs for a few times a year to give them some didactic training, and then while they're out in the field, they also provide some supervision. But they're always looking for practical projects for them to get involved in.

He [Mahoney] said, "Something like this--where we could use the CDC staff who we've got, who are based in the EOC, but who are doing frequent travel to Nigeria to work closely with them--they would value that. But in addition to that, there's a lot of them who are from the north. They know the north, [and] they can work up there easily."

At any rate, Frank put together a proposal for what this might look like, and to 01:27:00us this looked like a great idea. Tom Frieden agreed with this, and what had originally started out as this idea to put one hundred physicians in the north of the country eventually evolved into working with the FETP program.

We decided to call it the "Nigeria STOP Program," the NSTOP program. This ended up being one of our key contributions to what was going on in Nigeria. In fact, I remember a couple of years later, talking with somebody from the Gates Foundation, somebody who was oftentimes quite critical of CDC, saying that those NSTOPers were worth their weight in gold, that they really knew how to get things done.

Now, getting that up and running was a bit of a challenge. I mean, Frank is 01:28:00quite good at doing this, like I said. In terms of the organizational aspects of it, he could do it. The person who was running the NSTOP program at the time, or the FETP program at the time, Patrick [M.] Nguku, was very excited about this and very helpful in getting this organized. But there was some tension with WHO initially about this, because CDC, we had never had an operational presence in the country before. We'd had people posted there working on polio, but they were detailed to WHO and working within the WHO infrastructure. Now, we're developing something that's completely separate from the WHO structure and sending them up into the north of the country to assist with vaccination campaigns, with the 01:29:00surveys that go on after vaccination campaigns to look at their effectiveness, to work on advocacy. They were working side by side with the WHO staff up there, who were sometimes feeling very threatened by this initially.

I was actually concerned that the tensions could get out of control. But I was actually quite impressed with just how patient they were, just how patient the NSTOP staff were, and what they were able to put up with for a while before they got the sort of universal acceptance that they eventually had. The WHO staff really got to view them as valuable partners in this.

CRAWFORD: This is a follow-up question: you mentioned in a conversation with someone-- from, I think it was Bill & Melinda Gates Foundation--brought up maybe kind of a critical lens of CDC. I wondered about what kinds of feedback, comments you've heard about CDC as one of the partners?

ARMSTRONG: Yeah, so I should say this person who was making the criticism, he actually respects the CDC quite a bit, but [he] also had his own very strong opinions. He didn't agree with us about everything. [Laughs]

CRAWFORD: OK.

ARMSTRONG: First off, people, I think, really appreciate the technical expertise that we bring to the field. There is no other public health agency anywhere in the world that has the kind of capacity that we have, that has got the laboratory capacity, that's got the epidemiology expertise. There are other 01:31:00public health agencies that do--you know, we're not the best in the world at everything that we do, by any means, but there's no other place, I think it's safe to say, that has the breadth and the depth of expertise that we have here at CDC. People very much--I find that's recognized throughout the world, that CDC has that kind of respect. But they also appreciate that we can bring in the kind of technical expertise that we do.

Where I saw the biggest resentments was our limitations in terms of going out to the field, that we were nowhere near as mobile as any of the other partners. 01:32:00Certainly WHO. I mean, all of the UNICEF organizations are used to working in conflict areas. Gates Foundation also works in difficult areas--not probably to the same degree that the UN does, but they've got an infrastructure for managing that. Whenever we're overseas, we work under the embassy's security, and how much leeway we have to get out into the field depends on the security assessment. Unfortunately, one of the limitations that we had was that--this time period that you're talking about was after the Benghazi experience, where 01:33:00diplomatic security had come under fire because of what had happened in Benghazi. For that reason, diplomatic security officers were very conservative about what they would allow U.S. government employees to do. We could not get out into the field nearly as much as our partners could. There was some resentment about that, the fact that we just couldn't get out.

CRAWFORD: Thank you.

ARMSTRONG: Now, I'll have to just tell you, a lot of my staff were quite frustrated by that, as well. They would have liked to get out in the field. That would have been a good idea, just not--I mean it is true that being government employees, they're probably more of a target than they would be, being a UN employee or being a U.S. citizen who's not a U.S.-government employee. There are real reasons for that additional level of security. But it was, I have to say, 01:34:00for a number of the staff, it was frustrating that they did have to work within those limitations.

CRAWFORD: You brought up security assessments a few minutes ago, and that's kind of an opportunity for me to ask you about lessons learned, in terms of situational awareness--excuse me--and security assessments. Anything?

ARMSTRONG: Again, while we were overseas, we were largely under diplomatic security, which made me sleep a lot better at night, because they do have access to better data than we have access to about security threats. They've got people in the embassy whose full-time job is to monitor security and make sure that the diplomats and U.S. employees that are working there are safe. For us, it's not 01:35:00nearly as much of an issue as I think as it is for the other partners.

I think the one thing I'll say, sort of the one thing that dawned on me, you know: we had a meeting early on among groups at CDC who had some experience working in insecure areas. One of them said to me, "The thing you need to do is, you need to get everybody together, and you need to tell them that our number one priority is keeping everybody safe." I thought about that for a while and just [came] to the conclusion that it's not true. I mean, if your number one priority is keeping everybody safe, then you don't go into the country. If there's an outbreak of poliovirus in Syria, then you don't allow anybody to go 01:36:00in, because that's the only way you're going to keep people safe. The reality is that there is a huge amount that you can do to make people safer and to mitigate security risks and to limit the risk that people take. But the truth is, you're never--if you're going to be working in a place like Somalia or Syria or northern Nigeria, Afghanistan, you're never going to be able to get the risk down to zero. You should be honest about that. You really have to take a step back, [and] you have to say, "Why are we doing this? Why are we asking people to take these kinds of risks?" And you have to have a clear answer for that, because you are, as much as you can, as much as you're doing to mitigate those 01:37:00risks, you're not going to reduce them to zero unless you keep people home.

In the case of the polio program, the best estimates that we have, I believe we still have, are that if the polio program were to collapse, we would probably go back to having two hundred thousand polio cases a year. First off, polio would spread to every country in the world that has a suboptimal immunization system, which would cause large outbreaks. While it was doing that, large disruptive outbreaks, which would, in addition to the human toll, would just be very disruptive in terms of the economy. But then, once it settled down, you'd end up with two hundred thousand cases of polio a year. If the mortality rate is five 01:38:00percent, that's ten thousand kids dying every year. I mean, you can think about it. That's two hundred thousand kids getting polio. That's like an entire baseball stadium filled with paralyzed kids every quarter. Every three months.

That's why the people who are taking these risks are taking those risks. It's that there's a tremendous amount at stake here. In terms of the cost, it is a very expensive program, but the benefits from it, again from the same analysis, the benefits of it are in the billions even after we pay off the costs of the 01:39:00program. In fact, I believe it was the same analysis had estimated that there were four to eight million kids who had--through, I want to say 2010 or 2012--who had, oh God, I don't remember these statistics now. But I remember when you actually did just the raw cost analysis, that for the total amount that we'd spent to date at that point on the polio program, it had cost us probably two thousand dollars [USD] per case prevented, without even accounting for the savings in medical costs and without taking into account the future benefits of eradicating polio.

The other thing about polio eradication, or any eradication program, is that the 01:40:00benefits are just extremely equitable. Before the polio program began, the biggest benefits from polio vaccination were probably in places like the United States, where we had very high coverage and where there was no polio cases, where there had been tens of thousands of them per year, previously, whereas in lower-income countries, they still had very high rates of polio disease.

If you think about smallpox, since that was eradicated, your chance of you getting smallpox here in the U.S. are exactly the same as they are getting smallpox in Somalia or Syria or anywhere else in the world. It's zero. You know, 01:41:00when it comes to health equity, there's probably nothing that has more health equity than disease eradication. Everybody benefits from it.

CRAWFORD: I remember in the pre-interview you said--because if you live in a country like the United States, it's unlikely that you would be the first, certainly not the first to be affected by polio, because of our strong immunization programs.

ARMSTRONG: Yeah.

CRAWFORD: People in lower income countries would be more affected.

ARMSTRONG: Yeah. Again, if the polio program were suddenly to disappear, and all these resources were withdrawn, and polio had spread very quickly. But we'd see very few cases here back in the United States. They'd be disproportionately--these would be in low-income countries.

CRAWFORD: We were talking about Nigeria. Is there more to say about Nigeria?

ARMSTRONG: Nigeria? In early 2012, when the GPEI was scaling up, the program in Nigeria had lots of problems. It was quite clear, you could--when you looked at the numbers, there were some areas where they were vaccinating far more kids than could have existed in those areas. Then, after the vaccination campaign, you would go through and you found that they would miss a very large proportion. They missed a very large proportion of the kids. How is any of this possible? Initially, the program was just talking about doing more vaccination campaigns, doing more of the same thing, which just didn't make sense to most of the people 01:43:00in the polio eradication program.

It was clear that a lot needed to be done, and I would say one of the most important aspects of what got done was the establishment of the Emergency Operations Center [CDC Atlanta] towards the end of 2012. That did a few things. First off, the government was already in charge of the polio eradication program. But they're in charge of a number of different organizations. You know, the NSTOP from us, the WHO teams, the UNICEF teams. There are other organizations out there working on polio eradication. It's just hard for the government to actually impact what those groups are doing. One of the things 01:44:00that we found was that if, by bringing them together three times a week or whatever it was that they were meeting, really had the effect of empowering the government and building a coherency in the program that didn't exist previously. All these groups knew each other. If one of the programs was not doing what they were supposed to do, the other programs knew it, at least one of them did, and would call them out on it. If that group couldn't get done what they needed to get done, they would either, you know, be given the resources that they needed to do it or the task [would] be given to somebody else. It just really improved the cohesion, but also the accountability. The EOC was funded by the Gates 01:45:00Foundation, and one of the things that they invested in was some people to more regularly collate and analyze the data and so, the data was being presented much more regularly in a format that people could understand and make use of.

We saw, especially over probably the course of a year--that year 2013--that they really upped their game in terms of making use of that data: figuring out, you know, which data they could rely on, what data they couldn't, what data they were missing and needed to get.

It also really pushed innovation, because they were able to talk more frequently and more frankly about what the problems in the program were and just start 01:46:00brainstorming about how to fix those problems. There were just a whole number of--most of the innovations were relatively small that they were doing. But the sum total of them really improved the quality of the program that they were running. It also allowed them to really focus on where the problems were. You know, it's easy to look at the statistics from a vaccination campaign, for example, and say, you know, "On average, we did great," but that doesn't mean anything if the transmission is going on in a certain state. That state didn't do well in the vaccination campaign, and they're always not doing well in the vaccination campaign, because it's difficult to vaccinate there.

When you've got people together in a room like this and being presented with 01:47:00data and being encouraged to act on it, they tend to focus much more on where those problems are and what they're going to need to do to solve those problems. They don't let them sit around the way that they would have in the past.

I think that that year, 2013, was really critical for Nigeria. We really saw the program improve substantially.

At CDC, we had two people on the ground then that were key. One was Frank; he had continued to work there. The other was Hashim [A.E.] Elmousaad [MD, MSc]. Hashim is a former WHO official. In fact, he'd been the WHO representative in at least a couple of countries, I think. I know he was the WHO country representative in Yemen when Elias [Durry, MD, MPH] worked there years ago. But 01:48:00Hashim had known Frank and had asked him if he could get involved in this. Frank had convinced me that we should hire this guy as soon as we can and get him into Nigeria, which we did, and he proved remarkably effective. We couldn't bring him on as an employee, but we could bring him on as a contractor and that actually worked in our favor anyway, because he wasn't under diplomatic security, but he was quite used to working in insecure areas and so was quite used to working in the north of the country. [Hashim] was also just a very effective manager, and him partnered with Frank, partnered with this group of Nigerians and NSTOP, just made for a very strong team that really was effective at identifying problems, 01:49:00at solving problems, and really improving the management of the program in the north of the country.

[INTERRUPTION]

CRAWFORD: OK, so we've taken a break, and we're coming back now. We were talking about Nigeria, now we're, in the interest of time, moving into Pakistan. In your daily, day-to-day operations in EOC, when did you start focusing attention on Pakistan?

ARMSTRONG: Well, so Pakistan was always a big focus of the polio eradication program, being one of the endemic countries. But as a U.S. agency, it was difficult for us to work there. Our biggest contribution was Elias Durry, who we 01:50:00detailed to the WHO, so he was actually working under WHO at the time, running the program there. Elias is originally from Ethiopia, but has worked in some very difficult spots in the past in Yemen, in Somalia, and is very--one of those people, like Frank Mahoney, who's just very effective in the field.

But at the time, there were a lot of tensions in Pakistan that were making it difficult for us to work as U.S. government employees.

Then, on top of that, I believe this was in early or mid-2012, the movie Zero 01:51:00Dark Thirty1 came out, and in it they made an incredible mistake, which is that they showed a scene of this fake [polio] vaccination campaign that allegedly took place in an attempt to identify Osama bin Laden, rather than show it for what it was, which was a fake hepatitis B vaccination campaign. There were no hepatitis B vaccination campaigns out there, but that's allegedly what happened. They showed it as a polio vaccination campaign, which it was not; it definitely was not. But the movie made it seem like the polio program was in collaboration with the CIA [United States Central Intelligence Agency]. At the time, because 01:52:00of this carelessness in the movie, in part because of this carelessness of the movie--and because of other, you know, tensions in Pakistan, it was very difficult for us to send people there. We had very little presence on the ground but could work indirectly there. Elias was able to work very effectively there.

In addition to that, they also had a field epidemiology training program [FETP] that was involved in the polio eradication program. Elias was able to make use of them. In fact, he said they were some of the more effective managers he had out in the field. But in reality, it was--we couldn't send people there. We could help Elias from time to time with analysis or with other things that we 01:53:00could do remotely for him. I was on the phone with Elias from time to time, just to keep up with things, enough to know that--enough to be quite optimistic, actually.

By mid-2012, they had really improved the quality of the vaccination campaigns. They had improved the quality of the data that they were getting. Towards the end of 2012, going into the winter, the low season there, they felt they were in a position to potentially interrupt transmission for the first time. [They] put together a strategic plan to do exactly that, to intensify the vaccination 01:54:00campaigns over the winter and to try, for the first time, to stop poliovirus transmission in Pakistan.

CRAWFORD: Do you mean the national emergency action plan? Was that--?

ARMSTRONG: Yeah.

CRAWFORD: OK.

ARMSTRONG: Exactly. National emergency action plan. We were all quite excited about this.

But then, in late December--I think it was December 19, early in the morning--we started hearing these reports about shootings of polio workers in Pakistan. By midday, it was clear that there had been a set of coordinated attacks on polio workers throughout the country, that the vaccination program, or the vaccination campaign, had been shut down and that the program was dealing with an acute 01:55:00emergency. It was clear very quickly that whoever was doing this was targeting polio workers, something that we just had not seen before--that healthcare workers, polio workers, were being targeted for doing their job. It was also clear that this was going to severely disrupt the polio program for some time to come.

Now, back in Atlanta, we had been watching--watching the polio program from afar 01:56:00with a lot of optimism. We had been hoping that Pakistan could actually achieve what they were setting out to do, and interrupt poliovirus transmission. In which case, that would leave a--there are relatively few cases in Afghanistan at that point, and that would mean that we'd really be able to focus on Nigeria and have another success to point to, in terms of polio eradication.

But when that happened, we knew that this was going to set the program back for 01:57:00a few years, that Elias and the program in Pakistan [were] going to be dealing with some serious problems for some time, that we were going to have to focus on Nigeria; we were going to have to get Nigeria polio-free.

After that, unfortunately, the killings did continue. It was actually quite impressive what they were doing and just how much commitment the polio workers had to continue in the face of this. They did a lot to prevent the violence. But the truth is when the polio workers were being specifically targeted, it's hard 01:58:00to--there's no way you're going to mitigate that completely. It was, in fact, several years before the program really started to turn around again. I mean, it was actually really after it looked like Nigeria was polio-free--so this is probably around late 2014, early 2015--that Pakistan really felt that it was in a position to start making a comeback again and was ready for the program to start reinvesting in it and to start building up the program again. That's really been since then.

CRAWFORD: Was the role of the Emergency Operations Center in Atlanta at CDC that 01:59:00of sort of a bystander? How did it affect operations here?

ARMSTRONG: Yeah, so we had a--God, I'm blanking on the name now, but we basically had a Middle East team there that was, that had as part of its focus the--Pakistan, and so Derek [T.] Ehrhardt [MPH, MSN], who was running that team, was also in frequent conversation with the staff in Pakistan, including Elias, providing what support he could. But, again, that support--occasionally, we could send people in to help with trainings. We could send people in to help 02:00:00with sort of helping to think through organizational issues. But it wasn't possible for us to have a sustained on-the-ground presence, which is what we really needed to be effective, so we really were heavily reliant on the people who were there, which was the WHO team, led by Elias, the UNICEF team, and by some other groups there, including the FETP program.

CRAWFORD: If you were to say what the killings of community health workers meant for EOC in Atlanta, what would you say?

ARMSTRONG: I would say it was very discouraging. I mean, it was tragic. None of 02:01:00us have ever seen anything like this, that somebody would target a healthcare worker. We felt somewhat helpless about it. I mean, there was nothing we could do about it from Atlanta, and it was unlikely we were going to be able to get into the country. Even if we could, working as U.S. government employees, it would be hard to do. We were very reliant on--we were particularly reliant on WHO and its ability to work throughout the world.

CRAWFORD: This is 2012?

ARMSTRONG: Yeah.

CRAWFORD: Yes.

ARMSTRONG: This is the end of 2012 that this all started.

CRAWFORD: Moving forward in time: 2013. I just want to make sure that we hit 02:02:00turning points. One of them, to me, is actually, you mentioned that you were involved in the planning for the switch [introduction of IPV, inactivated polio vaccine, removal of poliovirus type 2 component from trivalent oral polio vaccine and introduction of bivalent oral polio vaccine].

ARMSTRONG: Only very peripherally.

CRAWFORD: Oh, OK.

ARMSTRONG: Yeah.

CRAWFORD: OK.

ARMSTRONG: There were other people at CDC who were more engaged in this, but at the EOC, we didn't. I don't think we actually had anybody while I was there who was involved in it. The switch occurred after I left.

CRAWFORD: But in the planning, what was your involvement?

ARMSTRONG: Mine? None.

CRAWFORD: None, OK.

ARMSTRONG: I mean, they had sent us some draft plans, and I made some comments on the plans. [Laughs] But nothing that was consequential.

CRAWFORD: OK. Twenty-thirteen turning points?

ARMSTRONG: Yeah. What were the turning points in 2013? I'm trying to remember 02:03:00now. I think there was also an attack on polio workers in northern Nigeria in 2013. I don't remember the dates. Fortunately, it was a one-time deal. Didn't occur after that, at least nothing on that scale. At the time we weren't sure if this was something that was going to continue. There were reasons to believe that it might not. There were, I think, ten people who lost their lives in the attack. But it didn't stop the program, and it didn't--you know, it was a 02:04:00setback, and it was another reason to reassess security of the staff we had in the field. But they were actually able to continue and to continue improving and building up the program there.

Yeah, what else happened in 2013? Can you jog my memory? [Are] there things that other people brought up? [Laughs]

CRAWFORD: I'm not looking for anything in particular, I just want to make sure that we cover up to 2015, when you got an offer that you couldn't refuse, and Anne-Reneé Heningburg [MPA] said that, yeah.

ARMSTRONG: [Laughs] Well, I, yeah--so when I came over there, I told them I would be there for two years, and I'd assumed when I started that we'd be out of the EOC by that point. We weren't. They were happy to have me continue, and I 02:05:00continued on for more than another year.

But the program was actually getting to a point where it was starting to evolve. It was looking like Nigeria was polio-free. It turns out it wasn't quite polio-free. We're hoping it is now, but they had a small number of cases about a year after we initially thought that it was polio-free.

Things are steadily improving in Pakistan. There had been for a long time, a lot of talk about what's going to happen after the polio program. What's going to happen with all this infrastructure that's been set up? What do we need to do 02:06:00now to make that we can make use of that? The obvious thing, the thing that we kept coming back to, was routine immunization, that these are immunization workers and that we should be able to make use of the infrastructure that we built up for polio to improve the rest of immunization. It's something that I felt that part of it-- that phase--was something that I felt that I was not in a particularly good position to run. I thought there are other people at CDC that have much more experience and much more talent in this area and building up 02:07:00routine immunization programs or other public health programs like that and that the program really needed somebody with those sorts of skills to take it into the next phase. I had stayed longer than I promised to stay. Definitely had mixed feelings about this, because I very much liked the mission of the group, and I liked the group of people I was working with. Very much enjoyed working on polio eradication. That's on one side.

On the other side, I also felt that the program's going into a phase where, actually a very critical phase, where it needs somebody who's got a different 02:08:00set of skills than I've got.

About the same time that this was happening, a new program had been established at CDC that was around pathogen genomics, a much more technical area than polio eradication, but it's something that I'd been involved with at CDC about ten or fifteen years earlier. [I] had left, quite honestly, out of frustration, because I'd felt that it was an area that had so much potential for public health. But as a relatively junior person at CDC, I was just not able to get across to others the importance of this, and now there was a technological revolution in DNA [deoxyribonucleic acid] sequencing that was actually making it possible to 02:09:00do far more than we were able to do, even back then.

Several people at CDC had come to recognize this and had actually pushed to get this program established, a thirty million-dollar [USD] per year program established. They sort of knew my reputation as somebody who's been advocating for this for a while. [Laughs] And so, it, for me, it seemed like a very important opportunity. It seemed like the stars were in alignment for me to move on. There wasn't any rush for me to move on. I spoke with Rebecca [Martin], the division director, about this for a while. I'd been talking with her about it a while, that I was thinking of doing this. We were able to make, I think, a very smooth transition.

CRAWFORD: John [F.] Vertefeuille [PhD, MHS]--

ARMSTRONG: Yes.

CRAWFORD: --became the next incident manager?

ARMSTRONG: Yes.

CRAWFORD: Could you talk briefly about that transition? How long it took to--

ARMSTRONG: John, I had never met before until I guess it was middle of 2013 maybe, when somebody put him in touch with me because he was finishing up a position in Haiti, running the CDC's program there. [He] was looking for another opportunity, and I told him, "Look, we need somebody in Nigeria. I know you used to be the CDC country lead there. Would you be interested in doing this?" And I knew that his wife was based here in the U.S., and that he would be based here in the U.S., as well, but doing frequent travel to Nigeria.

He was actually very interested in this. He'd seen the polio program back when 02:11:00he was the country manager many years previous. He knew a little bit about it. He knew a lot of the people there, understood how to get things done. At the same time--excuse me--at the same time, Frank Mahoney was thinking of moving on, and I needed to find somebody else who was going to take that over.

John agreed to come on, and I thought there was going to be probably a one- or two-month overlap between the two of them. It turns out actually, this was kind of a critical time in the program, and Frank decided that he didn't want to leave, and so suddenly, I've got two very strong managers there who also had 02:12:00very strong personalities. I was very nervous that this, that you know, this was just [laughs] not going to work out. But to my surprise, the two of them worked remarkably well together. I mean, they have completely different sets of skills. Yeah, different sets of priorities, but, you know, usually when you've got two people who are trying to co-lead something like this with different ideas, it does not work out. But in this case, to my surprise, it did. They were actually very effective together.

CRAWFORD: Briefly, what are those differences in skillsets?

ARMSTRONG: Frank is much more of a seat-of-the-pants epidemiologist. You could 02:13:00send Frank anywhere in the world; even if he doesn't speak the language, he'll be running things. People like him, they like working with him. He understands how to connect to people. He understands what motivates them, how to get them working together. In addition to that, he's also very intelligent, and he really sort of understands what's needed on a larger scale and how what he's doing fits into that. He's just, you know, you can put him on the ground anywhere, and he'll get people marching behind him.

John is more of a management type. He's much more comfortable working in a hierarchical situation, where he's managing things in a more traditional way, is very comfortable with the embassy, and with how things work there, and how to 02:14:00make use of the resources that the embassy can bring to something like the polio eradication program. I guess that's how I would sum it up. Frank is much more, I don't know, one-on-one, personality. He just, he gets along well with everybody and understands how to push things. John is much more of an organizational person, understands how to organize things--take advantage of the other resources that are there, like the resources the embassy has.

CRAWFORD: That's great. We're about to wrap up.

ARMSTRONG: Yeah. At any rate, so John had been working in Nigeria and been our Nigeria lead for a long time. By the time he took over, I'd gotten to know him quite well.

CRAWFORD: Super. I wonder--one of my closing questions, there are a couple, is I wonder what lingering questions you have, looking back on your time, about the polio eradication program, your involvement in it? Are there loose ends for you?

ARMSTRONG: Loose ends?

CRAWFORD: Loose ends in terms of things you wonder about. Could this have gone differently? Did we miss an opportunity here?

ARMSTRONG: I actually think things went better than I anticipated they would go. 02:16:00It's hard to say that--I can tell you that if we didn't have Elias in Pakistan, if we didn't have Frank and Hashim, and John in Nigeria, if we didn't have Derek Ehrhardt managing the EM [Eastern Mediterranean] region, the eastern Mediterranean region, and a host of other people, we just wouldn't have been able to get done anywhere near what we would have done. But if I had to single people out, it would be the Nigeria team, led by Frank and John and Hashim. In 02:17:00Pakistan, it's clearly Elias, who really built the program up to a top rate program and then carried it through a very difficult time.

CRAWFORD: You mentioned several times that he is very effective in the field, and we have three sessions with him.

ARMSTRONG: Yeah.

CRAWFORD: But I wonder if you could speak to that. What makes Elias Durry effective in the field?

ARMSTRONG: You know, there are a lot of people who train in epidemiology through CDC, and a lot of us have got good technical skills, in terms of being able to understand the epidemiology of something, analyze data. But there are very few who are good at management. I could name a few people around the agency who I 02:18:00know who are excellent epidemiologists but have real management talent. But then to find somebody who also has diplomatic skills? Who understands when you oftentimes, you hear people at CDC say somebody's being "diplomatic," they usually mean that they're being nice, but if you ask a diplomat, that's not what diplomacy is about. Diplomacy is about not making people angry, but it's more importantly about getting done with international partners what needs to get done--figuring out how to negotiate with them and to get what you need and make sure that they get what they need. Elias has got all those skills. He could work 02:19:00in a place like Pakistan, where he is an outsider. He's not Pakistani. He relates very well with people; he knows how to negotiate. He's not just nice and rolls over; he knows people like working with him. But he's good at convincing them to do what needs to get done. The people who work for him are very loyal to him. They really respect him as a leader and will follow him. That combination of diplomatic skills and management skills with a solid base in epidemiology that makes him effective at what he does. It's the same thing with Frank.

He's a very different kind of--has very different kind of diplomatic skill. But Frank is every bit as effective.

CRAWFORD: Any other thoughts, having had this conversation?

ARMSTRONG: No, at the time I was a little bit frustrated not being able to get out in the field more than I was. The incident manager job is really managing the things from CDC, so I sent a lot of people out in the field. [Laughs] I always felt like I had a good idea of what was going on in most places, where we needed to keep up with what was going on. But still, you never really understand 02:21:00things until you get out in the field. I think if I were to do it again, I would insist on getting out a little bit more than I had. Yeah, beyond that, there's very little that I think I would do differently than what we actually did.

CRAWFORD: Steve Cochi contributed this question, overall, if you had to do over again, would you work in polio eradication?

ARMSTRONG: Work for polio eradication? Oh yeah, absolutely. I'm really glad that I was able to contribute to the program at the point in time when I was able to contribute to it.

CRAWFORD: Great. I think that sums most of it up. There were two remaining items on my list, and they were the UNICEF Interdivisional Emergency Coordinating 02:22:00Committee, kind of the counterparts of EOC in Atlanta, is how I'm thinking about them. Is that a correct way of thinking about them? A RMSTRONG: You know, I don't know if that even existed when I was there.

CRAWFORD: OK, OK. Got it, yeah, this is from the CDC website. Strategic Health Operations Center is [SHOC] mentioned for WHO, as well. But other than that, we've actually covered everything in the interviewing guide. So, thank you so much.

ARMSTRONG: Yeah.

CRAWFORD: Yeah. I'll get a few spellings of names. Is there anyone else that you would recommend that we add to the list? We may or may not be able to include more people, but I like to ask.

ARMSTRONG: Yeah, so I know you said Frank wasn't able to, or wasn't available to talk with, but if you could change that at all, I think he'd be a great person 02:23:00to talk with. The stories that he'll tell you, you'll find fascinating. [Laughs] Hashim was with him, and Hashim can be quite articulate. Hashim Elmousaad, he was with him in Nigeria, and they're now in Pakistan. And, as I said, I ran into him a few days ago here. He was here in Atlanta. I forget, he told me how long he was, but he's another key person who I'd speak with.

Did you speak with people in the Gates Foundation?