Hugh Green

Hugh H.W. Green

Q: This is Sam Robson, here today with Hugh Green. Today's date is April 13th, 2016, and we are in the audio recording studio at CDC's [Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Hugh today as part of our CDC Ebola [Response] Oral History Project. Hugh, thank you for being here.

GREEN: You're welcome.

Q: For the record, could you state your full name and current position with CDC?

GREEN: My name is Hugh Henry Wescoat Green--double first name, Hugh Henry--and I am a public health scientist at CDC.

Q: Great, thank you. And can you tell me when and where you were born?

GREEN: I was born November 2nd, 1990, in Berkeley, California. Alta Bates Hospital. [laughter]

Q: Did you grow up in California?

GREEN: I grew up moving between California and Georgia. Spent about two years going back and--well, excuse me, about two years at a time in each place, moving back and forth. Then, I actually spent my first year in Rome, and then another 00:01:00year of high school in Athens, Greece.

Q: Wow, what--

GREEN: Sorry, yeah.

Q: Oh, yeah. [laughter]

GREEN: Not Georgia.

Q: Not Georgia. What prompted that?

GREEN: My dad works in sustainable wastewater technology and started a company out in Berkeley after getting his PhD there at the Energy & Resources Group at UC [University of California] Berkeley. My mom is an archeologist and works at Emory [University], and also works in Greece. She's currently the director of a site in Northern Greece.

Q: Got you. Do you think their occupations kind of shaped your interests?

GREEN: Yeah, I didn't think so as it was happening, but my personal interest is the intersection of urban design and public health, and how we design things that either make people healthy or unhealthy. Looking back on it, exposure to art history, to archeology, to architecture--that had a major influence. Then, my dad's interest in sustainable energy resources, water systems, technology, also played a factor. I almost went to architecture school and then realized 00:02:00that it was a little bit too narrow of a focus, and wanted more of a kind of broad, liberal arts experience.

Q: What were you interested in as far as high school, up to going to--

GREEN: Oh, everything. I have a hard time saying no to new experience and new classes, so I would repeat--I would overload on classes, I'd overload on sports, just fill my time as much as possible.

Q: What kind of sports?

GREEN: I was the captain of the lacrosse team, captain of the cross-country team. I played basketball. I swam. I sailed in the summer. Lots of sports. [laughter]

Q: Actually, yeah, which sports didn't you do? [laughter]

GREEN: Right.

Q: That's neat. At the end of high school, what were you thinking you wanted to do?

GREEN: That's a good question. I was definitely going to college, thinking about 00:03:00which colleges to go to. I applied to and got into all the UCs that I applied to, and I also got into some other schools. Emory was an appealing option. UC Berkeley was probably my favorite of the UCs. And they had just changed the tuition there, so it had gone up. And I had a scholarship at Emory, and so I actually paid less money to go to Emory. It was a slightly smaller environment where I could do all the things that I wanted to do. Because if I had gone to Berkeley, I could have done a sport or a social activity, and gotten into classes with two hundred people, and being taught by TAs [teaching assistants], versus going to Emory and having a small, more personal experience with professors, things like that. So it actually became a great choice.

Q: Can you tell me about it, when you--once you got there?

GREEN: Yeah. I actually really enjoyed Emory. Emory has been great for me. I kind of fell into public health through Emory. I probably wouldn't be here otherwise. But maybe that's premature. Freshman year, I did everything I could. 00:04:00I was an environmental science major, but I didn't declare that until the end of my sophomore year. Kind of just did English literature, biology, everything in between. I worked in a physical chemistry lab making solar cells. Lots of different things. I was a member of the Kappa Sigma fraternity, became the president of the fraternity. Also on the lacrosse team.

I realized that I had almost finished undergrad in three years, and that's when I heard about the BS/MPH program, which is a five-year bachelors in science and master's in environmental health program. I had missed the application deadline, but when I talked to them and I said that I had already finished all the requirements for undergrad, they were like, maybe this could work out. So I 00:05:00applied. I got in. I overlapped my senior year in the college and grad [graduate] school as well.

Q: What was that program like?

GREEN: It was great. There's a couple of professors who were in both the environmental science department and the environmental health departments. That's how I got the exposure. I took a class on--oh man, I wish I could remember the exact title, the name. But it was basically mixing environmental science, but more of a disease focus, and looking at all of these different factors from a more environmental, interested-in-ecology standpoint, impacting health. That was really cool. That professor was in both departments. I thought maybe I should check out Rollins [School of Public Health] and learn a little bit more. The classes that were listed and the syllabuses and everything looked 00:06:00great, so that's kind of how I ended up over there.

Q: Right on. This professor sounds particularly influential. Is that right?

GREEN: He was a really cool guy. He didn't have a whole lot of time, because he was just doing so many things all over the place. It was Dr. Tom [Thomas R.] Gillespie. He works in Madagascar with lemurs. He works on all sorts of different stuff. I definitely talked to him a lot when I was thinking about this particular move. And it was a great choice.

Q: Good deal. All right, so tell me about Rollins.

GREEN: Oh, Rollins was a great time. Let's see. My first year, I was kind of just there academically. I would go, take classes, come back, and have my social life with all my friends who were seniors. It was actually a very low-key experience. I think a lot of people, when they come to grad school, are coming from long-term either professional or just other kinds of experiences. It was really nice to mix that. I was, I guess, twenty-three, and I have people who 00:07:00were fifty-three in classes with me who are doing all sorts of really cool stuff, and I get to learn more from my peers than even from the professors in some cases. But that first year was very low key. I just took my classes. I did well. And I really enjoyed my social life over on the Emory campus. It was great. I met some great people. The second year I came back, I kind of--well, excuse me. I guess I did a lot more than I--I did a lot that first year. [laughs] I just remember it as a very good time. I know that there were a lot of people who were quite stressed about grad school. I wasn't one of those people. But it ended up working out really well. I applied for research funds to do a practicum in India. So I got money to travel to India and do a microbiological water-quality assessment of the Ganges River. I lived in India for a couple of 00:08:00months, collecting water samples along this holy river, which was pretty awesome. I also learned about the Urban Health Initiative, which is a group that is cosponsored by Emory, or I guess it's part of Emory. That provided a platform for me to apply to get more funds for more programmatic activities. I founded a community garden in Northwest Atlanta based off of grants that we had written over that summer. That was really exciting. Yeah, it was a great time.

Q: That's amazing. I want to hear a little bit more about India. Did you have findings that came from that?

GREEN: Yeah, the basic finding is what we already knew, which is this river is extremely polluted. Which, when you have a city that has something like four hundred million liters of raw sewage a day and no functioning sewage treatment 00:09:00plant, is to be expected. I think that part of it is the group I was working with is actually an engineering group, but also religiously affiliated. It's the Sankat Mochan Foundation. Sankat Mochan is a temple to Hanuman, the monkey deity. It was a great experience for me. I learned a lot. I think that what we were trying to do at the foundation was provide more of a watchdog to what the government was or was not doing. And they weren't necessarily providing adequate sewage treatment. This is also coming on a long period of trying to get more sustainable solutions. It was actually my father's company who--he and his mentor, when he was at Berkeley, had been visited by this delegation from India. That was almost twenty years before me going. They had this ongoing relationship 00:10:00there. I was just basically following up. The water is still polluted. This is the only group that's a nongovernmental lab that's even looking at the water quality. You've got people who take the holy dip and holy sip every morning. You're basically inoculating yourself. Yeah, it's pretty dirty. But it was a beautiful place. I think that's one of the points where I was more interested in global health, because I got to see a lot of life and death very close up. I had never been to such a rich country in terms of color, in terms of culture and things like that. As you walk down the ghats--these steps along the river--you see people who are bathing. You see people who are worshipping, people who are doing their laundry. But then, you also walk past the burning ghats, where they 00:11:00cremate the bodies of Hindus. You're just--every day, continuously. You experience this really profound juxtaposition of babies being washed in the river, and people being cremated and their ashes being sent out to be released from the cycle of samsara and go to nirvana. It's the city of Shiva--life and death. It was a great experience.

Q: Wow. Was it your first experience in a developing country? I know you'd traveled a bunch previously.

GREEN: First experience working, I guess, in a developing country. Greece is definitely not developing, but not fully developed either. Especially on the islands, it's--depending on what island you are, the non-touristy ones can be much more harsh. I lived in Greece during high school and worked there for four 00:12:00summers. Then I led an Environmental Brigades trip to Panama. Those are quite short though, and more of a service mission than actually working. And yeah, I guess most of my experiences prior to that had been in Europe rather than other places. Then, I actually did an internship in Hong Kong, which is like uber-developed. So, a very different experience. [laughter]

Q: Wow, yeah, no kidding. What was Hong Kong like?

GREEN: It was great. It's like the New York of Asia, except possibly more people, or at least it feels that way because it's so dense. Hong Kong Island is actually seventy percent park because it's so steep you can't build anything on it. It just feels really, really tightly packed. I guess you would feel that way 00:13:00in Manhattan or something like that. I was working for an engineering firm in their urban design department, doing urban design work, illustrated master plans, research on smart cities, and things like that. That was actually a great experience.

Q: When was that?

GREEN: I think that was 2011. So, I guess in the middle of my college experience, maybe the summer after junior year.

Q: Got you, okay. When do you graduate from the MPH [master of public health] program?

GREEN: Two thousand fourteen.

Q: Twenty fourteen. Okay. Up to that point, were there any public health figures or anybody who you'd say was particularly influential in your thought, or anything?

GREEN: Before graduating from public health school?

Q: Yeah.

GREEN: Well, I met my girlfriend, now of three years, in public health school. She grew up overseas. Her parents both work in public health, and she always 00:14:00wanted to work in public health. That was, I guess, pretty influential on me considering living and working internationally in a less-developed context. She's from DR Congo [Democratic Republic of Congo]--so, very much less developed. I visited this past summer, and that was a great experience too. It's just a different--people living everywhere, doing different things. There's a lot of joy in places with not much to have. The problems are different, or the--I mean, the people are the same. Problems are different. I think that was pretty influential in looking more into the global health realm.

Q: What happened after public health school?

GREEN: I had a little bit of summer, and then I basically came over here. I was considering three job offers, one with a technology company looking at transportation software here in Atlanta, another with a startup on more the 00:15:00water side of things. Then one of my favorite professors at Rollins, who also worked at CDC, said, "Hey, I've got this ORISE [Oak Ridge Institute for Science and Education] fellowship. You should check it out." I got a scholarship to be one of the scholars for the Aspen Ideas Festival in Aspen, Colorado, which was phenomenal. At that time, I was leaning more towards the technology side of things. There's a couple of different sessions, and the first one is all focused on health. I was seeing these really incredible people talk about health. Actually, Dr. [Thomas R.] Frieden was one of the speakers, and he was talking with two EIS [Epidemic Intelligence Service] officers about disease. At that point, I don't know if they were talking about MERS [Middle East Respiratory Disease], or maybe it was too soon to be Ebola. But it could have been Ebola, because they were talking about bats. Anyway, I went up and introduced myself, 00:16:00and I was like, "I'm considering a job at CDC." And he was like, [laughs] "Maybe you should consider it." I think, probably, that was the last thing he remembered of me. But yeah, I had this really dense experience of extremely important people talking about public health. And I thought, I just finished this master's. It would seem a waste to go straight into technology, even though I like the systems and the design of thinking about how a transportation system impacts health. It's a little bit indirect, whereas working at the CDC and working with this particular professor seemed like a very appealing thing that I may not have another opportunity for. So I went for it.

Q: Tell me about it.

GREEN: It was great. I worked in disaster risk reduction, which is all about prevention. My interest in public health came about from prevention. I'm not a clinician by training. I ended up working in the response, but I really was 00:17:00interested in diverting people from negative health outcomes. Disaster risk reduction kind of looks at--it's mostly used for environmental health and disasters--in environmental disasters. It's a little bit more difficult to look--but it's quite possible to look at outbreaks. It just hasn't been used as much in that framework, but if you think about reducing people's risk to the impacts of disaster. Either reducing their exposure, building up their resilience, decreasing their susceptibility to any particular onslaught like a hurricane, for example. If you evacuate a city and nobody dies, is it really a disaster? Or if you have an earthquake and every building is up to code, it's not really a disaster. However, if you have an inch of snow in Atlanta, it can be a disaster because we're just not prepared. That's where I was interested, and I got to work on some really cool projects. The first project was actually writing the emergency operations plan for an improvised nuclear device. CDC had 00:18:00to update this large annex, and I was on the team that was helping co-facilitate that. I got to work across a number of different CIOs [Centers, Institutes, and Offices] and meet people who were different subject-matter experts in radiation and all sorts of different fields. That was a really interesting experience. Then I also got to go--there was actually a huge conference for disaster risk reduction in Sendai, Japan, which was updating the framework for disaster risk reduction. I got to go to that, and that was also a really cool experience. Then, the final, culminating experience of my year at ORISE was doing the detail in the Emergency Operations Center, working on the Ebola response.

Q: Right. Tell me about that. Tell me about getting involved in the Ebola response for the first time.

GREEN: It was exciting. I had been interested in working on the response for a 00:19:00while. And they opened a new position, which was the task manager position for the incident manager. Essentially, they had all of these tasks that people were just too busy responding to things to actually get the other tasks done. My goal was to make the tasks more doable for the task forces, and then also follow up to make sure that they were accomplished. Essentially, we sit in every meeting that the incident manager was in, which was great because I got to meet tons of people, learned a lot, and also saw the decision-making process behind much of the response. Then, at the end of the meeting, [I] assigned tasks to the people in the room, based off of the conversation that had happened. Then, make those tasks smart, so that people could actually accomplish them on a timeline, and that they weren't too vague, and things like that. That actually helped the task forces do more, based off of what information they were given, because often we'd get these vague tasks. Like, I remember looking in the system and it was 00:20:00like, "Check on rent." And we didn't even know what country it was, or for what building, or anything like that. That would cause someone like me I don't even know how long to try to figure out what that was, so that we could actually inform the task force on what they were supposed to do. But by being in the room, and being on the calls, and basically being involved in most of the decision making--or not involved, but witnessing most of the decision making, I knew exactly what the context was for all of these tasks. Then I could figure out what was due tomorrow or today, versus what can we get done next week. I would work with the incident manager and say, "Here's the things that we think we should get done." And he'd say, "Okay, that's important, that's not important," and things like that. Then we'd go from there. It was a great experience. I was supposed to do it for thirty days, extended it for sixty days, and then I got called back. But by then, I had already decided that that's where 00:21:00I wanted to continue working.

Q: Cool. When did you start doing that?

GREEN: I think that was about April, so almost a year ago today.

Q: Okay, about April 2015. The incident manager at that time was--

GREEN: Dan [Daniel B.] Jernigan.

Q: Dan Jernigan?

GREEN: Yeah.

Q: You also mentioned you were close--were you already working with Barb [Barbara J.] Marston?

GREEN: I quickly realized that the vast majority of the tasks were going to the International Task Force, which Barb was the head of, and now is the lead for the Ebola Affected Countries Office, which is a branch in the Division of Global Health Protection. We just made that transition a couple of weeks ago, so I still think of her like the ITF [International Task Force] lead. Which in many ways we still are in response, with cases in Liberia and Guinea right now. That's how I first got to know Barb, and that's, I think, when she probably noticed me. When I expressed interest in continuing to work, that's when she 00:22:00started to set things in motion for me to be able to come and work for the International Task Force, which I've been very happy working with ever since.

Q: No doubt. Okay. Because I was going to ask--there were probably multiple task forces.

GREEN: Right.

Q: Originally, maybe--or maybe you always are working with all of them?

GREEN: The tasks would go to anyone and everyone, yeah, and not necessarily limited to the task forces. The way that the incident management system is structured, it should go to the task force and then it can go out to the CIOs [centers, institutes, and offices] and things like that. But some requests would go directly to other people based off of the need and speed of the request. So I got to work across. Basically, anyone who was tasked through the response, I would be following up with them, with a colleague. It was two people doing this, and we would tag team the activities.

Q: Who else was it?

GREEN: A guy named [Chee] Kin [Lam], who is up in New York now. He was great.

Q: Do you know what he's doing?

GREEN: I believe he's working for the Department of Public Health in New York. He was a PHAP [Public Health Associate Program] fellow. They got two fellows who were ready to put in extra hours for two months. And that's what we did.

Q: Okay, neat. [laughs] Can you give me an example of a certain assignment that was memorable to do? Maybe it was challenging, I don't know.

GREEN: In that particular experience, or with the International Task Force?

Q: With whatever task--yeah, with the International Task Force, actually.

GREEN: After finishing as the task manager for that two-month period, I came back to finish the ORISE position, and then took a little break. That's actually when I went to Congo for the first time. I went to Congo for two weeks, and then my paperwork came through for me to join the International Task Force. So I got back and started in the International Task Force in August.

Q: Okay, got you. Sorry, I was a little fuzzy on that.

GREEN: No, that's totally fine. I was basically detailed as an ORISE fellow to the response. Then I was officially picked up by the response. For the first couple of days, I was kind of like, all right, what do I do? And Barb just said, "Don't worry. There'll be lots of work." [laughter] Maybe on the third day, she said, "Why don't you look into survivors? What kind of services we are or aren't providing, what kind of medical issues there are?" I think on the fifth day--on Friday--I had a brief due to the director on what were the medical issues that survivors were facing. So it was a quick turnaround.

Q: Jumped into a deep pool, very quickly. How did you find out that you were assigned to the--what is it--ITF?

GREEN: Mm-hmm. I was actually hired by the ITF. Barb was my supervisor. So--

Q: Got you. So she reached out and said you should apply? Or what--how did that work?

GREEN: Well, I was--before that, I was meeting with lots of different groups, and I was particularly interested in working with her group. It's a great team. She's a superstar. That's kind of how that started. She said she'd like me to work with the group, and I said, let me know where to sign, and we went from there.

Q: Got you. Cool. Tell me about preparing that report to the director on medical issues faced by survivors.

GREEN: We have the world's experts here at CDC. I had the benefit of being able to work with them and learn about what people were seeing in the field, which is a lot of eye complaints, joint complaints, and things like--there's this huge 00:26:00range of sequelae that are experienced by survivors more than other people. We were trying to tease apart what were the issues that were related to the virus and affecting the people after they've recovered from that virus. There's three areas of focus, I would think, that are beyond just the medical. There's the medical sequelae that people face, then the kind of psychosocial-economic impact of surviving this terrible disease, and then also, the final thing is the viral persistence and the potential risk for transmission. What we're most concerned with there is sexual transmission. Those three areas became a big--that was how I would think about the various aspects of survivor services. Because we do less of the socioeconomic, livelihood support, things like that--that's more on the USAID [United States Agency for International Development] lane--we really 00:27:00focused on the medical sequelae and viral persistence. Because viral persistence is what the NSC [National Security Council] and other groups are really interested in as far as a risk for future introduction. That's where we've seen some cases of sexually transmitted disease, and then also what they're calling "flare-ups." It's possible that there is environmental introduction, but it's also possible that it's related to viral persistence. That's what we try to tease apart whenever we see one of these small clusters pop up. One of the legacies of the response has been being able to jump on those clusters very quickly. They haven't been able to become the same kind of epidemic or pandemic that we had in the past.

Q: You said you're surrounded by these world experts at the CDC, and that helps. Just tell me about learning about all of this--the process of taking in all the knowledge.

GREEN: Yeah, it's been fast. It's been really, really rewarding, and exciting, and I like to be challenged, and I like to learn quickly. I just listen a lot. I think where my skills actually play a role is synthesizing information. We've got information coming from all sorts of different people, people in different countries, people in different organizations, people in different groups here at CDC. I just try to pull it together and put it onto one piece of paper. That's an example of what the brief was like. We've got presentations on mental health issues. We've got presentations on Ebola and the eye, things like that. Just synthesize it down to what is that one bullet that says, "We have uveitis, and we recommend topical steroids." [laughs] The comment we got back from the director's office was, "You might also consider oral steroids for panuveitis." He drills down to that level of detail. You're trying to synthesize all of this 00:29:00information, and then that's the level of detail that is expected, which is incredible.

Q: From the director himself?

GREEN: I believe so.

Q: That's amazing. [laughter]

[break]

Q: One question I have is, were there any scientists or public health workers, anybody who you remember as particularly serving as an informant to you about these various issues?

GREEN: I think there's a lot to learn just from clinicians in general. Barb is a clinician by training. Sarah [D.] Bennett, who works on the ITF, is also a clinician. Whenever I had medical issues--or not my personal medical issues, but whenever I had medical questions, there are people in the room that know from a general clinician standpoint. As far as what we know about the virus, the Viral Special Pathogens group and people like Pierre Rollin and Barbara [M.] Knust and 00:30:00Mary [J.W.] Choi really explain how the virus--what we know about the virus based off of past outbreaks, and the history of the virus, and things like that. I think that the Viral Persistence Study in Sierra Leone and the Men's Health Screening Program in Liberia really help inform what we know about viral persistence, just because we've never had this many survivors before. Nobody expected virus to persist in various body fluids this long. We're rewriting a lot of the literature right now. It's been a fascinating time to learn. I think that, while I'm relatively new to this field of study, we're all learning at the same time, which is exciting.

Q: No doubt. This is something I don't usually ask in interviews, but you have a 00:31:00great skill--I guess it's because it's what you've been doing for the last over a year now--at explaining things at a macro level, and then being able to dig into the details of each little thing. And I appreciate that. I'm wondering if you could describe the basics of what this Men's Health Screening [Program] is in Liberia, and PREVAIL [Partnership for Research on Ebola Virus in Liberia] in Sierra Leone.

GREEN: PREVAIL is actually in Liberia as well.

Q: Oh, PREVAIL is also in Liberia? Okay, I really do need to learn about this! [laughter]

GREEN: Sure. I'll start with the Men's Health Screening Program. The Men's Health Screening Program is a Ministry [of Health & Social Welfare]-led program supported by WHO [World Health Organization] and CDC. Essentially, it's a counseling and semen-testing program. Survivors consent into the program, and then they receive sexual-risk-reduction counseling, condom demonstrations, things like that. Then, if they're willing, they'll produce a specimen which will be tested using RT-PCR [reverse transcription polymerase chain reaction] to 00:32:00see if there is any viral RNA [ribonucleic acid] in the specimen. If we detect viral RNA in the specimen, we let them know. In order for someone to graduate from the program, they have to have two non-detect samples. We're also very careful to say that it doesn't mean that there isn't any risk because we don't fully understand. A virus isolation by culture is one way of seeing if there's actually live virus there. PCR only looks to see if there are pieces of the viral RNA. It may be infectious, it may not be infectious. We're still in this time where we don't really know. We've got epidemiology that says that there is time after the virus isolation and before people go non-detect with PCR where 00:33:00there has been sexual transmission based off of a case in Liberia. There's this kind of range. PCR is the more conservative way to go, so that's what people have been using. But even then, we don't know if that means that there is no risk. We just let people know so they're able to make informed decisions. Then, also, the program provides referral if the people have other medical issues. That's where I was for the past month actually, was in Monrovia at Redemption Hospital. There are three sites, the largest of which is in Montserrado [County], which is the county where Monrovia is located. I was helping to support that program. It's primarily a counseling program with the semen-testing component so that people can make informed sexual decisions.

Q: Who is administrating the program?

GREEN: It's a Ministry-led program. Most of the staff are supported by WHO, and then CDC provides technical support.

Q: Right, that's helpful. Was this last month in Liberia your first time in West 00:34:00Africa, or had you been previously?

GREEN: It was, yeah. With the previously mentioned trip to Congo, this is my second time to the continent, first time to West Africa. Really enjoyed it--wonderful people, just a very warm, welcoming culture. Looking forward to going back.

Q: No doubt. This question just jumped into my head. It's not related, but when you were in Congo before, let's see--when were you in Congo? That would have been--

GREEN: I think it was July of 2015.

Q: July of 2015. That would have been after the little cluster in Congo had resolved.

GREEN: Yes.

Q: Okay, got you.

GREEN: Congo has had many outbreaks of Ebola. It's kind of every five years or so. But because it's so isolated, and there are experts who can speak on this better than I can, but one of the things that I realized very quickly about 00:35:00Congo is that it is a vast, vast country with very, very little infrastructure. Even though the capital, Kinshasa, is over ten million people and has relatively good roads and things like that, it has no sewage treatment for the entirety of the city. Or no centralized sewage treatment, I should say. Once you get outside of the city, it becomes grassland and things like that very quickly, with very, very bad roads. If you think about an isolated case of Ebola in a village that you can't reach unless you have a small plane to get you there, because there are no roads for hundreds of miles, it makes sense why they don't have the same kind of huge pandemics or things like that. It just is much more remote. My 00:36:00girlfriend's father actually had worked on previous Ebola outbreaks [laughs] in Congo, and we talked about it when I visited.

Q: Oh, really? In what capacity?

GREEN: He works in public health. Her mom also works in public health. They're both missionaries that grew up in Congo. Their group, IMA World Health, was doing primary health care and things like that during that same time.

Q: That is a neat coincidence.

GREEN: [laughter] Yeah, I know. He gave me a brochure that they had about Ebola. And I went back and started working on Ebola. It was kind of excellent timing.

Q: No doubt, wow. Okay, I think you had just finished talking about the Men's Health Screening [Program].

GREEN: Right, so there were some other programs and research projects. If we start with Liberia, the other major research project--so Men's Health Screening 00:37:00is a program, and it's a public health program for survivors. Then there's this large research joint venture of the US government and the government of Liberia called PREVAIL. And PREVAIL has a number of different things, but the largest one is the PREVAIL III: [Ebola] Natural History Study. The lead for HHS [US Department of Health and Human Services] is NIH. National Institutes of Health is coordinating the study, and that's looking at lots of different things. It's basically trying to figure out over the next five years, what is different about survivors? What kind of viral persistence do we see? What body fluids is that affecting? They have different sub-studies looking at--they have an eye sub-study, for example; or a neurologic sub-study; a birth cohort looking at, are there differences with women who survived Ebola and then became pregnant, or 00:38:00women who were pregnant and subsequently delivered? That type of thing. They're really trying to understand the disease course of Ebola now that we have this huge population of people who have lived through it. Both the Men's Health Screening Program and the PREVAIL Natural History Study are located in Monrovia. Those are the major things happening. Then, there's also clinical care that's being offered all over the country by various other groups, mostly in the primary healthcare public sector. But then there's also private groups and NGO [nongovernmental organization] groups that are also providing for survivor care.

Q: Right, okay. I want to get back to here, of course, but I also want to make sure we haven't missed something. We mentioned how--was it your first week that Barb said, "Hey, maybe you'd like to look at survivor issues?" You submit the 00:39:00report to Tom Frieden.

GREEN: Yeah. [laughs]

Q: What does your work consist of leading up to when you actually went to Monrovia?

GREEN: There's kind of three major areas. I'm trying to think about how to frame it, but there's the scientific work, which I'm not necessarily doing the primary science, but I'll contribute to and work on various things with people who are trying to understand how this disease works. I would constantly be trying to learn, what's the latest information that we have about viral persistence? What's the latest information we have about medical complications? Learning information from the field, learning information from experts here, and trying to gather that information and then report that up to the incident manager, and then also at the director updates. There's that side of things.

There's also the US government trying to figure out its policy. What kind of 00:40:00programs are we going to have, or how is this going to affect various other things? I work on a number of talking points--briefs, that kind of stuff--to discuss, how do we deal with this issue? Because it's a large issue. There's a huge population that needs care. In many cases, they need care urgently. For uveitis, for example, there's an acute need there where you can prevent someone from losing their vision depending on how quickly you treat it. So there's that kind of thing. Then there's also the long term. We don't even know how this is going to affect people, but one of the major complaints is joint issues. Rheumatology, stuff like that--that's going to be an ongoing issue. How do we care for these people? And then also, how do we manage the potential risk that they may pose via sexual transmission, now that we know that virus persists? So 00:41:00kind of marrying the science into the policy and trying to figure out how it all works.

A third area, which grows out of--now that we've decided what we think we should do, is: how do we actually do that? One of the things that I really enjoyed was working with the CDC Foundation, because they have funds that can move more rapidly than some of our existing funds, which were all programmed out before we thought--or, I shouldn't say that. But before survivors became a large issue, we had already made our game plan. Then, survivors. Now we start to realize, oh my gosh, we've got thousands of survivors who have all these issues. What do we do about it now that we have already programmed all our money? The Foundation really was able to come in and support a number of projects that we thought were worth supporting. So kind of coordinating that work, asking countries, what do 00:42:00you think is something we really need to do based off of these needs? And them saying, these are the various partners that are doing good work, and this is the type of stuff we want to support. Making sure that those proposals fit both the headquarters agenda and the needs in-country, and then linking the funds with the people who are trying to do the work.

Q: What are some of those projects that you've helped marry the funders and the doers together?

GREEN: I think possibly the largest is Partners In Health in Sierra Leone, which is providing eye care nationally to survivors. They're also supporting Project Shield, which is a counseling and semen-testing program. It's more widespread on the counseling standpoint--we still have to work out a little bit more of the testing side of things. But that is a national initiative that's also aimed at 00:43:00helping people make good sexual decisions and providing sexual-risk-reduction counseling and things like that. That was a large project. There's also been more directed clinical support. We've got [34th Regimental Military Hospital] in Sierra Leone, it has a survivor clinic that was supported by the Foundation. We're also looking at a similar type of thing in Liberia that's currently in the works. Really recognizing, okay, we've got the needs of the individual from a medical standpoint, the needs of the population from a risk-reduction standpoint. How do we address that? How do we creatively use these donor funds that were given for the epidemic and for control of Ebola and say, okay, this is continued--this is ongoing control of Ebola. We're not necessarily in response mode, but we are avoiding going back into response mode. That's where it was 00:44:00exciting, getting back to my interest in prevention. That was how I kind of--I can claim no real authorship of any of these things, but just facilitating and making sure that everything was coordinated. It was great to be able to work on both sides, with the Foundation and also with the people in the field who were saying, "These are the things we need."

Q: Project Shield sounded a lot like the Men's Health Screening Project.

GREEN: The Men's Health Screening Program is a little bit more robust, I would say. There are more survivors in Sierra Leone than there are in Liberia, and the focus has been to provide counseling. They've done a good job of rolling out counseling to a large group of people very quickly. But the Men's Health Screening Program has that kind of sustained follow-up, and there's a lot more testing going on. The Men's Health Screening Program has graduated, I think, 00:45:00over seventy percent of the people who have enrolled. There's probably updated numbers on that. It's probably higher than that at this point in time. But they're really following up with people, and if there are people who go longer, they're encouraging them. It's more of a client-counselor relationship, less of a "let's reach a huge population and make sure that they get this message because it's an important message to disseminate."

Q: The fact that that exists brings to mind that CDC is still not the only actor in--

GREEN: Right, of course.

Q: --in Liberia and the other countries.

GREEN: Yeah.

Q: As you said, some of your work has been working with some of those other partners, like Partners In Health, helping them to get the funding through CDC Foundation. Can you tell me about continued work with the partners and CDC, and working to--I don't know if there's work to organize the continued response at 00:46:00large with survivors? I don't know if I'm making sense right now. [laughs]

GREEN: Yeah, you're making sense. My interaction--the country officers have far more interaction with individual partners, and especially people who were working on co-ags [cooperative agreements] and things like that. I only came into it later, with the Foundation-type work, and then also when I deployed I worked very closely with WHO. I think that WHO in Liberia is the relationship that I'm probably best suited to speak to. As far as working with other partners, the people in-country are the ones who are actually talking to the partners and saying, okay, this is what we want, this is what you can provide; let's work on a proposal. And then the proposal would come back to headquarters. So it's a little more secondhand there. But actually going to the countries and 00:47:00working with people, I think that that's where the relationships are made. That's how the work gets done. We basically provide a support role while we're here at headquarters and let people know the latest information. But we're also trying to learn the latest challenges so that we can support as much as possible.

I worked very closely with WHO. Most of the program staff at Redemption [Hospital] were employed by WHO. Some were employed by the Ministry of Health, and I worked on a day-to-day basis with them. Great people. I think that any working situation is not without challenge, but most of our challenges were related to power going out, things like that. Trying to make sure we saw everybody in a given day and make sure that we followed up with everybody appropriately. A lot of times I'd have to gently remind people to do something. 00:48:00For example, the receptionist. I was like, "Did you call all of these people on this list?" And he's like, "No, I'll call them tomorrow." I was like, "No, I need you to call them today." That kind of thing. But it was always more of a friendly relationship. I think we were able to accomplish a lot together, and it was great to be a technical consultant from CDC because I was able to speak to some issues with that authority behind me. And in other ways, provide general management recommendations and stuff like that. But it was really WHO managing WHO people, and then we're all working under the umbrella of the Ministry. It was a great way of working collaboratively with this partner and learning about some of their strengths, and providing some of our strengths from the data quality and scientific assurance side of things.

Q: It sounds like--and correct me if I'm wrong--but the WHO staff, they're local staff who are employed by WHO?

GREEN: WHO has both international staff and local staff. Most of the people who I was working with are local staff. Our counseling lead was international, from Uganda, but all the other people I was working with on a day-to-day basis were from Liberia. When we'd have our management meetings, then we'd have people who are more of the WHO management who are working on different aspects of the response like case management or infection prevention and control, things like that. They were from different places as well.

Q: Are there any particular people who really stick out in your memory, at the moment, who you'd like to describe a little bit?

GREEN: From Liberia, or just in--

Q: From Liberia, yeah.

GREEN: Everybody was very warm and welcoming. I really enjoyed working with them. I think that I learned a lot from the program coordinator for Redemption, 00:50:00Jomah [L.] Kollie. Often, he would make a decision, or he would say something, and I'd be wondering why he did it that way. Then I would talk to him afterwards, and he'd explain this whole backstory, and there was all this context that you just don't have, going there for a month. I was like, oh, I totally understand why you made that choice. I learned from him, and I learned also from that experience to take a backseat and listen, because this is not my country. I went in with a sense--I tried to be humble, and I tried to have that attitude. And then, I'd ask him after we were outside of a meeting or something like that, "Can you explain?" And there was a good rationale behind it. I just needed to have that rationale explained to me. That was a big learning experience for me.

Everybody was really great. I'm trying to think. Yeah, it was really fun. I 00:51:00really enjoyed getting to know my driver, as well. I had a WHO driver who picked me up every day and drove me home every day. I got to learn about his family, and we took a trip up to Bong [County] to visit the program site there. There's three program sites. And I basically tried to have people explain things to me, and then I would see if they matched my understanding of what it should be beforehand. If there were any differences, then I would say, "Can you go into a little bit more depth?" Through that process, I saw some things that should be changed, and was able to say, I know you've been doing it this way, and this is how I understand it. Do you think we could move it more towards that? Which people seemed to respond well to. Sorry, that's a little tangential, but that 00:52:00was part of that trip.

Q: No, that was--that's actually really good. Do you have an example of one of those things where you--matching expectations with what you see, and then--

GREEN: Yeah. We had learned that they had been using--in this particular situation, they'd use the refrigerator compartment instead of the freezer compartment [for specimen storage]. It was only because I asked to see where the thermometer was, and I realized that the lead was going into a different place. Just by asking questions, and just by observing, we were able to see that, and then correct it, to make sure that we were doing things the way that they ought to have been done. That was just one example. We were able to fix the situation, and no harm done. Everyone learned from the experience, and it really worked out.

Q: Were there times when, going through that process, it went the other way, and you realized, actually, CDC now needs to change something that it is doing?

GREEN: Well, I think that we realized some of the limitations of the--of things 00:53:00that weren't foreseen when the program was started. One of the big issues was funding, for example. Nobody expected people to continue to have viral persistence this long. When we've got people in our program who haven't graduated yet, and the original funding ends on March 31st--we've got the end of the response here. We've got OFDA [Office of US Foreign Disaster Assistance] saying it's no longer an emergency. We've got WHO saying it's no longer an emergency. Then we kind of had to scramble. That was when the relationship back here at headquarters, and knowing all the people here, and Barb was able to jump on it and say, here are a couple of different ways we could solve this. And we were able to find a solution quickly. That was one of the things where having already worked here, knowing the people here, and just explaining the situation 00:54:00and saying, hey, I've asked a couple of times, and it doesn't seem like they have any money next week. What are we going to do about it? We were able to find a solution, and the program is still going.

Q: Right on. [laughs] No, that's fascinating. Thank you for bringing up the formal end of the response on March 31st. Clearly, a milestone. As you said, an event that had real consequences for who's involved--who continues to be involved, and that kind of thing.

GREEN: Right.

Q: Can you just describe a little bit more about that? About what happened with the transition, and how things continue from here?

GREEN: Yeah, I guess I can only speak to my personal experience.

Q: Of course, please do.

GREEN: I came back from Liberia that weekend, right before the end of the response. I came back into work the 31st. Previously, I had been sitting in the 00:55:00Emergency Operations Center, right in the middle of the floor. I was surrounded by a bunch of people from the International Task Force, a high-energy environment. The 31st comes around, end of the epidemic. We no longer have as many seats in the Emergency Operations Center. We are now spread into different places, and it's just--it doesn't have the same kind of feeling of energy in the room. There was almost static in the EOC that you could feel, where everyone's working really hard. It's just a different--it's a different feeling. That's how it comes across to me. There were also little things, like all of a sudden we're like, we need to get new bridge lines and stuff like that, which is just logistics, but you don't realize it until you don't have it. I have a biweekly survivor services coordination call. I had to find a room to find that. 00:56:00Normally, I would ask the day before and the guys in ops [operations] are so fast. They'll just be like, okay, you've got this room, no problem. All of a sudden, we have to fend for ourselves, and we don't have this giant apparatus doing things to make sure it works. I think that my plane flight to get out to Liberia--the ticket wasn't purchased until a couple days beforehand. That is no longer possible. We don't have all of those luxuries of people who are working 24/7 [twenty-four hours a day, seven days a week] to push it forward. I think that we are doing fine. I think that the new branch--the Ebola Affected Countries Office--is doing the exact same work that it was doing before. We just don't necessarily have the apparatus behind us, or that room with the same atmosphere. But we're adjusting, and I'm sure it's going to work out great.

Q: Thank you for bringing it back to your personal experience. I appreciate 00:57:00that. I've asked you a lot of questions about these broad things, when generally, in oral history, we try and go the personal route. But again, you're really gifted at describing things. Thank you for that. Can you tell me, then, about you personally? About how you see your near and longer-term future?

GREEN: Well, let's see. [laughs] I'm currently Title 42, so this is a two-year position, and I'm one year into it. The mid-term plan is to move internationally and work in public health. My girlfriend is currently applying for an MBA [master of business administration] at Emory. If that happens, I'll be here a little bit longer, but the plan is to move afterwards. I think in the next two to three years, probably planning to move somewhere internationally. Right now, she would love to move back to the continent. I think East Africa is appealing. 00:58:00I would also like to be in West Africa after having worked in Liberia. I'm really open to anything, just more global health work, more international work. And then eventually, long-term plan, want to marry that global health, public health background with more of the urban design work. I really got into public health through urban design, and then left urban design behind for this new mistress of global health. I would like to bring them back together. I think that the basic unit of civilization, at this point in time, is cities. I think that if we can design our cities better, then we can really effect massive public health benefits. I think that climate change is going to make that all the more necessary. We're a mostly coastal species. We're a mostly urban species. Our cities and our food systems and our water systems will all soon be 00:59:00feeling the effects more. Now is the time to act. Now is the time to adapt and mitigate any potential threats. That's more of the prevention work that I am interested in. If I can use my design skills, if I can use the experience that I've built through public health, long term, to pull these things together and build healthier places, then that will be great.

Q: Is there anything else you have left that you'd like to make sure we have on record, about yourself, about your experiences in Liberia, Ebola response in general?

GREEN: I guess that I never thought I'd be sitting in this seat, and I'm very happy to be. I just took opportunities that came to me. At Emory, I studied the courses that sounded interesting, and I kind of fell into public health. Then, 01:00:00after doing my master's in public health, I was looking around and got this opportunity to come work at CDC, which was a great opportunity. While working on a detail, which was another opportunity, I got picked up by a really great team. Through that, I've gotten to work on this subject and with these people that are just so amazing. It was really wonderful for me to actually, after having worked for almost nine months on survivor services, actually have the opportunity to go and work with survivors. Many of the people who are in the program staff for the Men's Health Screening Program are survivors. Our beneficiaries that are sitting outside the room waiting for counseling and other services are all survivors. To hear their experiences, to know that they made it through an Ebola treatment 01:01:00center and now they are still dealing with the consequences--and then also to share their joys, and being able to move on with their lives, and to leave Ebola behind and not let that define them--it's been an extremely rewarding journey, one that I couldn't have predicted even a year and a half ago. I feel very grateful to be here.

[break]

Q: Okay, we're back from a short recess. Hugh, you had talked a bit about Redemption Hospital, and what that looks like, what the environment is actually like.

GREEN: I can only imagine what it looked like in the early days of the response. But when I got there, it is this sprawling complex. You drive through New Kru Town, which is one of the most densely populated parts of Monrovia, but all single story. Very dense. Some of it looks like a shantytown. You get to this 01:02:00hospital, and it's all painted yellow. There are various kind of banners, like "make sure you're taking your malaria medication," "make sure you get an HIV screening if you're pregnant," and things like that. Then you walk in. Somebody scans you to take your temperature, which is still required. You wash your hands, which is still required. All carryovers from Ebola. Then you wind your way back. You wouldn't necessarily know where to go at first, but then you go past the generator room, which is important because the generator always goes out and you've got to make sure it comes back on to keep your samples cold. Then you come into this large room. You look down the hallway, and there are over one hundred mothers and babies. The Men's Health Screening Program is at the end of the pregnant and new infant ward. You pick your way through the legs of all of these mothers and babies who are sitting there in the oppressive heat, waiting 01:03:00for someone to see them. Then you come into this end of the hallway where we have a counseling room and a little office. Open up the office and hope the electricity is on. There's four other people in this little room, and that's where you work for most of the day. The actual participants will sit outside with the mothers and babies. It's like this huge mass of humanity right outside of the room. Then, the actual place where they go after they're counseled, to produce a specimen, is basically this concrete box. There's a screen on one side, and various instructions. When you think about how all of this happens in this environment, it's a miracle that it all works out. We've got these file cabinets full, everyone's case report. I'll check the case report to make sure 01:04:00that we didn't miss anything before it gets entered into the database, and that's how we make more programmatic decisions and know who to follow up on, and things like that. But the place itself is pretty impressive. And eye-opening to what primary healthcare looks like without an electric power grid behind it, without running water, and with a catchment area of over thirty thousand people at this hospital, which is serving this community. How you can run a Men's Health Screening Program out of three rooms in a building like that, at the end of the ward with all of these mothers and babies that you've got to pick your way through. I just wanted to describe that, because every day it was just like, whoa, here I am.

Q: Well, I appreciate that. It's an excellent kind of oral painting of what it's like. So, thank you.

GREEN: Yeah, my pleasure.

[break]

GREEN: We were just talking about particular people who I've come to know through this response. I was thinking that there are people that I work with on a day-to-day basis who are great. The country support staff and the technical team here. We have fun together. We can get to know each other. But then, there are also people who I have never met, and now have relationships through email and phone contact. I'm thinking about this one person in particular, Charles Alpren in Sierra Leone, who became the survivor lead at a time when we were trying to figure out who's going to be the point of contact for each country. He just stepped up in this huge way. I would ask, "What do we think the semen-testing coverage is for this country?" And then, boom, I'd have this gorgeous spreadsheet being like, here are all the people that we've counseled and that we think we've tested, and blah, blah, blah. And I don't even know this person. I've never met this person, but through these communications, and on the 01:06:00phone, it's this virtual relationship. I think that there are a lot of those in the course of the response, just because the work is happening over there, and we're doing a different kind of work, doing the support work, and more of the policy-level work and things like that. But we rely on people in very remote places, in different countries. We try to share the information that we've learned from Liberia with Sierra Leone, with Guinea. You learn a lot from being there, but then you also rely a ton on the people who are there day in and day out, long term. Taking that one step further, CDC is still relatively young in these countries. There are people who have been there for even longer. I haven't had personal interactions with many of these people, but various folks who set up clinics after the war in Liberia and stuff like that, and have just been 01:07:00there throughout the entire process. Ebola is just one more thing. We came in, and we performed a very important and necessary role. But there will continue to be problems after Ebola. It's this larger continuum of history where we just enter--we've entered and we've had a very important and impactful presence. And I think that we will continue to. But then, there is also this tip-of-the-iceberg type thing. I guess that's also tangential, but just to say that there are really wonderful people who I've never met before that do great work. And I feel like I've gotten to know then totally virtually, which is cool.

Q: Well, I appreciate that. I appreciate the sentiment, and I appreciate that vision, that knowledge that Ebola is just one little segment, that historical 01:08:00consciousness, essentially. So, cool.

GREEN: And I think that there are other people who have come into public health at other pivotal moments. I think that pandemic flu was another major moment in a lot of people. That's how they interact with a lot of emergencies. Nine Eleven [September 11th, 2001] and bioterrorism was another major moment. Ebola is the one that I've been a part of, and will probably be how I compare things in the future.

Q: Anything else that you'd like to add for the record?

GREEN: I don't know. I keep thinking of new things. [laughs]

Q: Well, and you do. And that's wonderful. Actually, as you do--because this might stir up things over the next couple of days. I've had a few people do second interviews just based off of other things they remember. I'm always open to doing more of these, and setting this thing up.

GREEN: Okay, great, yeah. Well, I'll let you know if I think of anything else.

Q: Please do.

GREEN: Yeah, this has been fun.

Q: Okay, I'm glad that you've had a good experience.

END