Dr. Kimberly Lindblade

Dr. Kimberly A. Lindblade

Q: This is Sam Robson here today with Dr. Kim Lindblade. Today's date is June 8th, 2016, and we're here in the audio recording studio at CDC's [Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I am interviewing Kim as part of our CDC Ebola [Response] Oral History Project for the David J. Sencer Museum at CDC. Kim, thank you so much for being here with me, and for the record, could you please state your full name and your current position with CDC?

LINDBLADE: My name is Kimberly Ann Lindblade, and I'm an epidemiologist with CDC, currently the influenza program director for the CDC office in Thailand.

Q: Thank you. And can you tell me when and where you were born?

LINDBLADE: Oh. I was born on November 17th, 1966, in Macomb, Illinois.

Q: And did you grow up in Illinois?

LINDBLADE: I was there until I turned around eleven, and then my parents got divorced, and we moved with my stepfather to Italy for three years and then after that moved back to the [United] States to Phoenix, Arizona.

Q: What kinds of things were you interested in as a kid?

LINDBLADE: I actually was interested in medicine from a pretty early age, although at some point my next-door neighbor, who was studying medicine, had to bring home a head to dissect, and my parents were very excited for me to be able to watch him do this, but I think it completely turned me off medicine. [laughs] I got a little grossed out. But I also--I read a lot. I really loved reading, and my father's an outdoor enthusiast, a really big canoer, so we spent a lot of time canoeing rivers and going biking and outdoor stuff.

Q: Tell me about what kinds of things you started to get interested in in high school especially. It was--

LINDBLADE: In high school, I did a lot of--I actually got into drama, so I was in the drama club and did a lot of performances, musicals and plays. I was not very sporty. I didn't do any sports at all in high school, but I attribute some 00:02:00of that to having been in Italy as a middle school student and never really getting started in any sports, so when high school hit I was far behind everybody. I was academic. I did well in school. I was president of the National Honor Society my senior year and president of the thespian club, which I liked the juxtaposition of those two roles. But, yeah, pretty typical. At that point I don't remember knowing what I wanted to do exactly. I wanted it to be something international. The experience in Europe really changed my life in profound ways. It really opened up the world to me, and I knew at least at that point that I wanted to do something that was related to international activities.

Q: What do you mean it opened up the world for you?

LINDBLADE: Well, I think I'd lived a pretty closed existence in Illinois. My 00:03:00grandparents traveled a bit after they retired to Europe, but we didn't have connections overseas. We didn't know people who lived overseas, we didn't know people who traveled a lot. I always think about it, too, that my mother was very typical--you know, the kind of food she made was very Middle American. I can remember lots of casseroles with crumbled up potato chips and a lot of white bread. Then after we lived in Italy, and she learned to cook Italian--because she's actually an excellent cook--then we were having involtini or all sorts of Italian dishes that were really amazing. So our entire diet shifted after we lived in Europe, and we ate better and ate fresher. We traveled a lot through Europe and Italy, and I just became really interested in what was going on in other places. At that point, even though we were living in Arizona, so kind of 00:04:00in the Hispanic part of the world, I never looked south. I was never interested in going to Central and South America, but I was very focused on Africa. I think probably because of living in Europe and having that more direct connection. So I was always focused on trying to go to Africa. It was only later that I ended up in Central America and really loved it, but early on that was not my focus.

Q: So where did you go after high school?

LINDBLADE: After high school, I went immediately on to university--University of Arizona--and spent about four years there before I got a scholarship to go study in France. I originally was supposed to go to Senegal. I wanted to learn French in Senegal--I had already been speaking French for a while, but I wanted to improve my French in Senegal. But I could never get admitted to the university, so I ended up going to France and spent a year studying French in Bordeaux, which I don't recommend. It's a very kind of cold part of France. People are not 00:05:00very open to outsiders. But it was a good experience. I definitely improved my French while I was there, and had a chance to go to Morocco, so the first time on the African continent. And then I had to go back. I wasn't quite ready with school, so all in all it took me six years to finish undergrad. While I was in school, I switched majors a couple of times. My father, who was also a college guidance counselor, suggested that I look at international public health because he knew that I had this interest in medicine and that I also had this international focus. When we looked up what that was, some of the majors that were suggested included microbiology, so I did an undergraduate degree in microbiology and then took a class my senior year--or maybe it was my second senior year--at University of Arizona called the Ecology of Infectious Diseases. The idea that there was this link between infectious diseases and the physical 00:06:00environment and that changes in the physical environment could affect disease transmission just fascinated me. I knew that was the area I wanted to focus on.

I applied to the University of Michigan--the University of Michigan School of Public Health. That was the only place I applied, because my grandmother lived there and I wanted to go back to Michigan. When I first went to talk to them about international public health, a very wise person said, don't go into that department. You need a skill. You need to study epidemiology. So I did. I did a half international, half epi [epidemiology] program at Michigan for two years in the master's program and wasn't sure I wanted to go into public health. I wasn't so enamored with the work that was going on at Michigan or the professors, but stuck with it and decided to go on for a PhD rather than take some time off. So 00:07:00I went right into the PhD program my third year there. I was still fixated on this idea of environmental change and infectious diseases but didn't know how to operationalize that, what kind of thesis would I do? What kind of project could I do that would capture that idea? Having that idea, I decided to take an opportunity with the Population-Environment Fellows Program that Michigan ran with USAID [United States Agency for International Development]. In fact, I was one of the first to go out under this fellowship program. They had previously had a Population Fellows Program, and they would send out recent MPH [master of public health] grads [graduates] to work with population agencies around the world, family planning agencies. This was back when we were still very concerned about population growth, and it kind of morphed into the idea of women's rights and family planning. So they had this program, first it was just about population planning and family planning. But then, when there was also this 00:08:00realization that those issues are meshed with environmental conservation issues, they created the Population-Environment Fellows Program to look at both population and environment issues together.

I had gotten a position with CARE in Uganda and went out to Kabale in the far southwest of Uganda after my third year in the PhD program. I took a leave of absence and worked for CARE for about two and a half years. They had both a family planning project, and they had a development and conservation project, and I was supposed to bridge those two and see where their natural overlap was. It was an unbelievable experience. It's one of the most beautiful places in Africa. It's a highland area with terraced hills and beautiful lakes and a great climate. It's Africa, but I was sleeping under a down comforter, so it's very--it's just very pleasant and beautiful, and I had a wonderful two and a 00:09:00half years learning how to work in Africa and making a lot of friends. Ugandans are very warm. They had been kind of coming out at that point--this was 1993--coming out of the war and very open to outsiders. I had some great times there. While I was there, I had a friend who was doing her PhD on colonial agricultural practices, and she came across an article written in 1945. The British at that point were very concerned about overpopulation in Kigezi, this area of Uganda, and had started to actually relocate large parts of the population to other places because they were worried there would be environmental collapse. But while they were looking for other solutions, they also began to reclaim swamps that were at the bottoms of these valleys. So the valleys are 1,800 meters, really high, but on all sides there are still hills or 00:10:00mountains that will go up to even 2,100 or 2,200 meters. So they started to drain and cultivate in these swamps, and at the same time--well, it appeared that they were creating ideal breeding sites for Anopheles gambiae. So whereas there hadn't been any malaria at this high altitude previously, now they were creating these long rows of berms and ditches in between, and water was collecting. Whereas there had been these very thick papyrus swamps before, now the papyrus was being harvested and cleared out, and so sun was reaching these pools of water, and they became, at least for certain times of the year, very good breeding sites for Anopheles. The idea was that this change in the environment had led to an upsurge in malaria. I had this a-ha moment, like this could be my project. I've got defined environmental change and the potential for having effect on infectious disease. I got very excited, and I went back. By 00:11:00that time Michigan had gotten a new professor who was interested in similar issues, and so I had somebody to work with. I got funding and eventually went back about a year and a half later and started my research and ended up comparing--could find some sites along the papyrus swamps that were still intact and compare them to sites that had degraded, that is, cultivated swamps, and was able to show a difference in mosquito density in those areas and in temperature. It seems to have changed the microclimate in the area and made it warmer and, of course, sunnier, and it probably accelerated the whole development of the mosquito and the development of the parasite within the mosquito and was probably the reason why malaria had resurged in the highlands. While I was there, there was an El Nino event and actually a huge epidemic of malaria, which in public health, you end up being grateful sometimes for the things that you 00:12:00shouldn't. But I think if that epidemic hadn't happened, I wouldn't have had enough data to get my thesis done. There actually was a huge upsurge in malaria while I was there, so I was also able to describe--because I was measuring mosquito density, and I was measuring parasitemia rates--I was able to describe this epidemic as it occurred and report on it very quickly, so that was an opportunity I had not anticipated. Then while I was there, I ended up working on malaria because at the time I was only one of two people working on malaria in Uganda, which now is amazing to think of because there are literally thousands of people working on malaria there now, but the country was just reopening. There was a small malaria community in East Africa, and I ended up meeting some of the CDC folks who were working in Kisumu just across the border in Kenya. When I finished my PhD, they offered me a job at their field station working on the second two years of a large randomized controlled trial of insecticide-treated bed nets. So shortly after finishing my PhD--well, actually 00:13:00before it officially was awarded, I moved out to Kenya to take up this position with CDC and KEMRI [Kenya Medical Research Institute], and that was the start of my CDC career.

Q: Wow. How did that study proceed?

LINDBLADE: Well, that study was humungous. Bed nets at that point, they had been around since at least--well, bed nets had been around since Cleopatra, but the idea of treating them with an insecticide had been around since the eighties, and this was now 1999. So there was already a lot of interest, and I think WHO [World Health Organization] was already moving towards recommending the use of [insecticide-treated] bed nets. But there were still some data that needed to be collected from very high-intensity malaria areas. There had been about four studies in other parts of Africa of either seasonal transmission or low endemic 00:14:00transmission, but places like Kisumu that have--at that point about 80-100% of the population was parasitemic, so these really intense malaria transmission areas they hadn't yet done an [insecticide-treated] bed net study. The study started in 1996, before I got there, and they randomized something like a hundred--no, 220 villages to either receiving [insecticide-treated] bed nets at the start of the study or two years later. Then when I got there, they were giving [insecticide-treated] bed nets out to all the communities, but the question became: if you have children who are protected from birth from malaria, will they get malaria later in life? And could it possibly cause more harm if they became infected later than maybe when they were--if they were infected earlier, when they were still protected by some maternal immunity and maybe even younger age? The part of the study that I worked on was to try and determine whether there was any increase in risk in older children who had been protected from malaria since birth from [insecticide-treated] bed nets. And we found no 00:15:00evidence that they were at increased risk, and in fact the cumulative benefits were really overwhelming. That was part of the last piece of the puzzle for the international community to really grab [insecticide-treated] bed nets and run with it, and it's amazing now, but literally probably a billion bed nets have now been given out, and most of them for free in Africa. We've seen substantial declines in malaria prevalence in large parts of Africa, and I think a lot of it has got to be due to insecticide-treated bed nets. It may not be the final answer. We still have a long way to go with malaria transmission, but it was a really critical intervention.

Q: And where'd you go from there?

LINDBLADE: I was there for about four and a half years, and then my supervisor at the time--I remember we were at Easter dinner, and he turned, and he said, "Would you be interested in a job in Guatemala?" And I thought, oh, yeah. 00:16:00Actually my husband had traveled to Guatemala to see a friend a few years before and really liked it, and I thought, yeah, sure, that sounds great. We had a son at the time, but he was still very young, and so we were very footloose and fancy-free. In 2004, we picked up and moved to Guatemala. I had never been there and didn't speak Spanish, but we went for language training. I worked at the CDC office, which is based at the Universidad del Valle de Guatemala in Guatemala City. I started off working on onchocerciasis. River blindness was endemic to Guatemala. It was imported into the Americas from Africa at some point, probably during the slave trade, and there were the right kind of black flies in many parts of the Americas, so onchocerciasis became endemic although it was never quite as bad as it was in Africa. There were never sort of blind people being 00:17:00led around by small boys as you saw in Africa, but it was still a problem. We were working with the Onchocerciasis Elimination Program of the Americas to measure transmission in different foci and to work with the government on their control program, which consisted of twice annual dosing with ivermectin, which is a microfilaricide. There were four foci in Guatemala when I got there, although one of them we evaluated pretty quickly and it seemed to have probably been defunct for quite a while, although sadly--my interest is environmental change--it was kind of the negative environmental change, where it looked like pollution had actually destroyed the breeding sites for this black fly. So I did that for a couple of years, and we were able to evaluate--by the time I left, three of the four foci had been evaluated to be free of transmission, which is 00:18:00great from a public health standpoint, but as an epidemiologist, it gets a little boring to constantly be measuring zero, just calculating the confidence intervals around zero--oh, it's zero, and [laughter] it's great, but yeah, you--as I said, you end up wanting the things that are not necessarily right for the [public health]--I would like to deal with a case [of disease] every once in a while.

CDC started the International Emerging Infections Program in Guatemala, and so I applied and became the first director of that program. For about three years, we established surveillance for the common causes of diarrhea, respiratory disease, and neurologic disease and eventually added on febrile illness of unknown origin. Guatemala is almost a middle-income country, or it's a lower-middle-income country, so it does do some things pretty well, but it's still really poor in many places. They don't have a lot of epidemiologists, and 00:19:00they don't have a lot of information about burden of disease, so we were able to determine what were the most important causes of respiratory illness and diarrheal illness and basically set up a platform that could be used to eventually evaluate the introduction of new interventions. We set up the surveillance in the departments of Santa Rosa and Quetzaltenango and were able to measure the incidence of different diseases. Then when the rotavirus vaccine was introduced in [2010], we were able to evaluate its impact on the number of cases and age distribution and all sorts of other epidemiologic outcomes. We also did a lot of work on outbreaks and supporting the Ministry [of Public Health and Social Assistance] in helping develop their capacity to identify and investigate and respond to outbreaks. I got involved in the H1N1 response, as we 00:20:00were neighboring Mexico when it broke out in 2009, and we had an outbreak of diethylene glycol poisoning in Panama that we assisted with, and several other local outbreaks in Guatemala. It was a really good time. It was a great group of people, and everyone worked really well together, and I really, really enjoyed Guatemala. As you know, it's still one of the places where people wear traditional dress. It's a very colorful and beautiful country. Just the mountains and the rivers and the lakes and the coastline, it's just gorgeous. I sure hope it can pull itself out of its corruption and crime issues that it still deals with.

Q: You were there for quite a while. Was it '99 when you got there? I forget--

LINDBLADE: No, 2004 I moved to Guatemala and left in 2010.

Q: Where did you go from there?

LINDBLADE: Then we moved back here to--well, I should say we moved here to Atlanta, we had never lived in Atlanta before. I came back to the malaria 00:21:00branch, which I had been in when I was in Kenya, and became the team lead for the Strategic and Applied Science Unit. The malaria branch has four teams. One is devoted to implementation of programs, and that's mostly the President's Malaria Initiative team, a very large and important team that tries to implement all of the known interventions for malaria. There was my team, which was much smaller but focused on research and public health evaluations; and then they had the domestic team and the laboratory team. So for three years, I led a small team, and we worked on a number of issues. Maybe slightly ironically, one of the studies that I ended up leading was to evaluate whether [insecticide-treated] bed nets were still working. By that time, insecticide resistance had really gathered steam, and there was a lot of concern throughout Africa that with insecticide resistance, [insecticide-treated] bed nets would no longer be very effective. So we undertook a study in Malawi, an area that had some, I would say 00:22:00moderate resistance to pyrethroids of the major Anopheles vectors and tried to evaluate whether users of [insecticide-treated] bed nets were still better off compared to non-users of [insecticide-treated] bed nets. We worked on that for a couple of years and actually showed that [insecticide-treated] bed nets were still quite effective even despite the insecticide resistance, and maybe it's partly due to the barrier effect, that it's not just a vehicle for insecticide, but it also has a [permanent barrier] --I mean, it has a physical presence [barrier] that prevents mosquitoes from biting. But the bottom line was that [insecticide-treated] bed nets still work, which was a very--I was very happy to be able to pass that message on. There's still concern, and it's still something that has to be monitored, and insecticide resistance could become more intense, and so we can't let up. Hopefully there are a lot of people out there working on new technologies to try and make sure that this important intervention remains.

Q: You were doing that until when?

LINDBLADE: I did that until the end of 2013. So I was here almost exactly three years. My husband did a master's during that time, and I thought we were here for a while. But our kids were getting older, and we realized that we had maybe two windows to be able to go back overseas. Even though they were both born while we lived overseas, they didn't really remember it. We wanted a chance for them to be older, to experience life in another country. The job in Thailand for the flu [influenza] program opened up, and flu is one of the programs that's overseas that still has a really strong research component. I really respect the flu people. I was interested and applied for the job, and we moved to Thailand in January of 2014, and I've been there ever since.

Q: How have you and your family found Thailand?

LINDBLADE: I've had to warm up to it. I was surprised, but after so many years 00:24:00working in Africa and Central America, there's--the Asian sensibility is just a bit different. It's just a different style that I've had to get used to, but I think I've basically cracked the code now, and I understand how to operate, and I enjoy the people. They're very fun-loving. They really like team spirit. They really like to work together on projects, and that's always a good thing. So yeah, I'm enjoying my time. Our children love the school that they're going to, and it's fun to live in a big, urban city for a couple years. It's a very big, dirty, loud city, but we can walk out on our soi, which is our street. We can walk out at any time of day or night, and there is just so much life on the street and so much activity, and that's--I don't know, it's stimulating.

Q: You're in Bangkok?

LINDBLADE: Mm-hmm [yes].

Q: You were there when the Ebola epidemic started becoming big news in the 00:25:00spring of 2014. How did you get involved in conversations about the epidemic?

LINDBLADE: I remember hearing about it, yeah, in probably March/April 2014, so I had only been in Thailand a short time when I started to hear about it. If I remember correctly, the first big call for volunteers came in July, and I was on home leave at the time, or--yeah, I was on R-and-R [rest and relaxation] home leave back in the States, and I immediately sent in my name and CV [curriculum vitae]. I just felt this overwhelming urge to go. But the process was still--you know, people were scrambling to try and get people out, so I never heard anything. I don't know where my name went, [maybe] into this big list somewhere. So I didn't hear anything, and several months went by, and it was September, and 00:26:00somebody came on TDY [temporary duty assignment] to the office in Thailand who had just recently been out to Liberia, and I remember asking them, "How do I get there? I keep sending my name." I think I had sent my name in three times, so I was like, "How do I get to go?" And they mentioned that Barb [Barbara J.] Marston was the main person, and she's an old friend of mine from Kenya, so, oh, I can just email Barb. So I emailed Barb, and that just started things happening. They scheduled me to go in October out to Liberia.

Q: You know, this is going to be completely out of order, but actually one question I have is looking back, are there people at CDC who really stand out to you as influential, you've worked with them quite a bit--people like Barb who--yeah.

LINDBLADE: Yeah, there have been so many. Barb is one who is just the most solid, wonderful person that you can imagine, and yes, she was--she worked for the Global AIDS [acquired immune deficiency syndrome] Program in Kisumu when I 00:27:00was there. Just really a dynamic [person] and--just somebody who gets results. And their daughters are around the age of my children, so we used to travel together and hang out. But I can remember one time trying to organize something with her, and she was unable to do it because she was developing a budget for the Global AIDS Project of, like, a hundred million dollars, and I remember thinking, how in the world do you budget a hundred million dollars? But Barb did it, and she achieved remarkable results getting so many people--you know, setting up all these clinics to do good HIV [human immunodeficiency virus] care and getting all these people tested and on treatment, and really, really remarkable. Her husband, Larry [Laurence] Slutsker, who was my boss in Kisumu and then again here in Atlanta for a few years, and just a wonderful fam--a wonderful person. The two of them together are amazing, but Larry just--so 00:28:00funny, such a dry sense of humor, such a warm person, always welcoming, always ready to talk, and one of the best scientists I've ever known. I love to have him go through my papers because he sees things that no one else does, and he helps me reframe things. He's now retired from CDC, so I'm really going to miss him. And then Kevin [M.] De Cock, who actually arrived in Kenya right around the same time I did in 1999 and became our Kenya country director, and just heard him speak again on Monday, and every single time I just--I love hearing him talk, because he just gives you a vision, like a perspective on things, and he frames stuff--he's able to take what's going on and reframe it in a way that gives you a whole new perspective on it and new insights into what's going on and comparisons with things that have already happened or other diseases, and 00:29:00just makes you think. Really inspirational, no matter what he's talking about. So I've really appreciated working with him as well.

Q: I have the great privilege of interviewing him as well as you today, actually. [laughs]

LINDBLADE: Kevin? Oh, good, good. Well, tell him I said hello, because he's definitely one of my--yeah, one of the public health greats.

Q: So October, right? You land in Liberia in Monrovia?

LINDBLADE: Yeah, land in Monrovia and not sure what I was going to do, which became the modus operandi for everyone: land in country and wait to be told what you're going to do. It was raining. It was a little depressing at first. I had never been to West Africa, so I was excited about getting a chance to go there, but had never been there. The part of Monrovia where most of the CDC operations are is literally right on the coast, so you can see the ocean right from the hotel. Josh [Joshua A.] Mott was our team lead for--I can't remember what the 00:30:00position was called, but essentially the epi team lead, or the epi team lead for those of us going out to the field. He was on his way out to support a remote outbreak, and so he gave us a very brief orientation and told us to get our stuff together, and we'd be moving out in the next day or so, and we had to attend an RSO [regional security officer] briefing. But [he] put me in touch with [Dr.] David Blackley, who was going to be my partner out in the field, and told me I was going to Bong County, about four hours from Monrovia. He also told us to go out and eat something because we never knew when we were going to eat solid food again, so we went and had a big lunch at the hotel. Within a day or two, I was on the road. I went out with James [Heffelfinger] first. He got dropped off in Margibi County on the way out to Bong, and there we met up with 00:31:00David. David came with Sampson [V.K. Dolo] and another David [Vourjoloh], our driver. We were really fortunate we had a team from Peace Corps. Peace Corps had provided four teams of a driver and a local--well, it's one of their program people, but to act as a facilitator, as a community liaison. We had one of these teams, Sampson and David, and they picked me up in Margibi, and we went to Bong. Along the way, David [Blackley] started to fill me in on what was going on there.

I don't even remember how we started, but I think one of the first things was we went and paid a courtesy call on the county health officer, Dr. Samson [K. Arzoaquoi], and started to get the lay of the land and what was going on. Met with the WHO representative [Dr. Moses Jerunlon] and the county surveillance officer, who was named Emmanuel [D.] Dweh, and started to try and figure out 00:32:00what was happening. What was going on with cases in Bong, how many cases they'd had and what information they had on them, where they came from, how many contacts they were tracing, and what kind of system they had set up to be able to identify and monitor contacts, what was happening with their hotline, what was happening with their data entry and with their ability to get information on cases and analyze it, what was going on with treatment. Bong was actually a really lucky county because they had an Ebola treatment unit in town, or up on the hill in town, and they had a lab [laboratory] that--the [United States] Navy had established a lab at a local university, so they had a lot of support right there in the county.

There weren't that many cases when we first got there. They were kind of sporadic. Pretty quickly we decided that we needed to go out to all of the 00:33:00districts within the county and get a sense of what their capacity was and make sure that they had materials. It was the WHO team. There was the head, and then there was an assignee from Ethiopia [Gebru Gebrukrstos] who had actually come out to do I think malaria work, but because of the crisis they reassigned him to work on Ebola. So they had done some training of the district people already on contact tracing, but it was kind of surprising that this was October. The epidemic had been in full force for several months, and yet there was no standardized training material in the country for either case investigation or contact tracing. We didn't get to it, either, until many weeks later, but we decided to go out and at least talk to people and find out what they were doing and make sure they understood the procedures that needed to be followed. We went around to--I can't remember how many [districts] there are, probably eight or 00:34:00ten [districts]--and CDC was very nimble at that time, so we had a lot of freedom to do what we needed. This is Africa, where people don't have a lot of money, and so if you're going to call people for a meeting, you need to help them with the transport or reimburse them for their transport and provide them with a lunch, so I needed a fair amount of cash to be able to do this. There was one rusty ATM [automated teller machine] at this university in town, and so every day I would go and pull out the maximum that I could on this ATM--because you never knew if it was going to be working, if the power was going to be on from one day to the next--and went to all of these districts and called all of these people in. There would usually be the district health officer and some number of contact tracers that--there were about fifteen that were getting some support, theoretically, from one of the NGOs [nongovernmental organizations] that was supporting contact tracing in Liberia. We would talk to them, and they 00:35:00would tell us about how many cases and how many contacts they were following, and we would go through the procedures with them. It was a good thing to do because we got to see immediately what was really happening on the ground and what the limitations were. But also, that little bit of incentive of the transport and the lunch was important for people to feel like they could continue to do the work but also have a little bit to help their family with the situation that they were in. I felt like it revitalized a bit the whole response effort.

Q: And that was something they hadn't had.

LINDBLADE: They hadn't had, and it became a problem throughout Liberia, that there was a patchwork of NGOs that had been funded by a patchwork of donor agencies, mostly USAID, but there were others as well who were responsible for either case investigation or contact tracing. Then you also had the safe burial and ambulance [teams]. You had a variety of these different response aspects, and so different groups were responsible for [activities in different counties], 00:36:00and sometimes it worked and the agency was effective in it, and sometimes it didn't. Later on, we did an inventory across all of the counties and districts within the counties in Liberia to see who was responsible, who was getting paid, who wasn't, who was trained and who wasn't, to try to make sure that there weren't these gaps in places that might end up seeing cases where we were not ready to deal with them. In Bong, we just did it locally.

One really sad thing that we didn't find out until later is we went to--I can't remember the district, Jorquelleh--one of the districts that we went to, we had a meeting there with all of the contact tracers and the team that was doing the case investigation and contact tracing. And later on one of them, his son fell ill in Monrovia, and he went back to Monrovia and brought his son home with him. Even though he had been trained in Ebola and knew about the disease, he never 00:37:00apparently thought that his son might have it. His son ended up dying, and there was a big funeral, and a lot of his siblings and his mother and aunts and uncles and relatives came to the funeral and touched the body and washed him and helped bury him, and that resulted in twenty-seven additional cases, and most of them died. So this man, who was a contact tracer who had brought his son back, ended up losing his wife and three of his children and his son, of course, and all of his neighbors and relatives and he got run out of the area. I went back, and I checked our--you know, since we were giving out money we had sign-in sheets and receipts and stuff, and I could find his name on the list of our participants. But unfortunately that information that we gave him wasn't enough to help him save his family.

Q: Did that happen with him while you were there, or was that something you 00:38:00learned after?

LINDBLADE: Not while I was personally in Bong. At that point I had passed up to Monrovia, but the group that came after me, it happened while they were there. It was in the town of Tayla-Ta [also known as Taylor Town].

Q: Did you know that contact tracer?

LINDBLADE: No, I don't remember him. At each meeting there were fifteen people [or more], and he didn't stand out for any reason there.

Q: Can I clarify just one minute? [gesturing to bottled water] Yeah, that's for you. Sorry, I should have told you that. The ETU [Ebola treatment unit] that was there in Bong, who was running the ETU?

LINDBLADE: It was International Medical Corps. Is that right? IMC? I would have to look it up. [note from K. Lindblade, Aug. 2017: This is correct]

Q: Were you also evaluating the testing that was going on and the communication 00:39:00between the lab and the ETU?

LINDBLADE: Yeah.

Q: How was that?

LINDBLADE: There were a number of challenges. When a case was identified, it could be identified in a couple of different ways. Sometimes people would just show up at the ETU. Especially in the later stages, that ETU had a very good reputation, and so there were people coming from across--especially a lot of people from Monrovia would come up-country because they didn't trust the ETUs in the city, so they would come to Bong and kind of just show up. The Bong County surveillance officer might not know of those cases, so they would try and have regular meetings with the ETU in order to get the case information. But other times they [the cases] would be found by the surveillance teams, and then they would have some record of the cases before they went to the ETU. There was an attempt to make sure that the two sides were talking and that there would be 00:40:00ways to get forms back and that we would duplicate the data and make sure we had the information. But actually at that time, too, our sense was we needed to quickly respond to any case and identify the contacts, identify the contacts and get them monitored and evaluated. We deliberately, actually--I shouldn't say this as a CDC person, but we kind of deliberately did not worry too much about the data that was getting entered and sent up to Monrovia. We just needed to focus our limited resources on stopping transmission in Bong County. We did try and facilitate some of this information exchange, but definitely our emphasis was on identifying these clusters of contacts and making sure that they were getting seen every day and monitored and having their temperatures taken if anybody became sick and then taken for testing. Because [the] Bong [ETU] was 00:41:00right there, in comparison to many other places, the data were not as bad as what was going on [elsewhere]. We were also working on the flow of information about deceased cases. We needed to hear about all the cases because we needed to be able to get out and make sure that the contacts had been identified. So we were working on integrating information coming from the alert calls, the help desk, the calls that were coming--you know, people would just end up alerting various random people within the county health office, and so trying to make sure that that information was coming in consistently and that we knew what was happening and then integrating it with the lab data so we knew for sure whether people were confirmed or maybe even not cases. That was a lot of our effort. We began line-listing what we called the contact cluster--these were people who 00:42:00were basically all exposed at the same time because of a case, or at least their last exposure was at the same time--because then the case would have been taken to the ETU. We put up big sheets of paper in this room that was being used for the surveillance office, and we would just put out basic information about the cluster and when they would graduate out of their twenty-one-day monitoring period. Kept that focus on monitoring those clusters because we knew that that's where the next cases were most likely to come from. The team started to really become very effective. The surveillance officer would call the right district health officer every day and make sure those clusters had been seen.

The other thing that we realized is that again, it's Africa, and communication is very difficult, and even though there's pretty good cell phone penetration, people don't have money on their phones and they're reluctant to use their own money to be able to make calls. Even though the NGOs that were responsible for 00:43:00the case investigation and contact tracing were also supposed to provide phone cards, it just didn't happen. Having to physically pass a phone card is too difficult when you've got these districts that are so spread out, and you have to call them all in, and then they're away from their jobs for a day, and you pass them these phone cards every month. Or there's a way of developing a caller's group--a caller user group in which you could pay directly to the phone company, and then everybody could call each other in this caller user group for free. That was a big effort that we decided that could make a huge difference, them just being able to communicate better and call for an ambulance when they needed one or check up on whether the contract tracing was happening. I remember thinking at that time, we just need some billionaire to just say he's going to pay Liberia's phone bill for six months. Like, let's think outside of the box, and let's think big. Just pay for the phone bill, and you're going to see a 00:44:00remarkable decrease in transmission when people can talk to each other. Even though I ended up meeting an NPR [National Public Radio] reporter and told her this idea, and she said she really liked it and was going to tweet it, I don't think she ever did. But anyways, we developed this caller user group and then we had to go around and collect all the phone numbers of all of these districts. We eventually got them all signed up and got the US Embassy to pay for this, and by that time--it actually took a long time, but that was starting--I was in Liberia for two months, and I think we finally got that off the ground about two weeks before I left. It was motivational to the members of the surveillance team, because they could of course use that free calling for other things as well. There's a lot of logistics when you're living in these remote, poor areas that can be facilitated by telephones. But I think also just to be able to get the information they needed when they needed it was very important.

Q: Can you describe David Blackley a little bit and what it was like working with him?

LINDBLADE: Have you talked to him?

Q: No.

LINDBLADE: Oh, he's another great, great person to talk to. David was an EIS [Epidemic Intelligence Service] officer. He's tall and lanky, very thin. It turns out he's a long-distance runner, which I didn't know at the time. I think he brought two shirts and a pair of pants, and he would just wash his shirt at night. He had one of these quick-drying shirts, and so every night he would wash out a shirt. He would just--in fact, I saw him in pictures, you know, like a year later. He's been going back to put out some of these later outbreaks, and every time I see pictures of him, he's still wearing one of the same two shirts. [laughter] He was fantastic. He works for NIOSH [National Institute for Occupational Safety and Health] in Morgantown, [West Virginia], so he was used to dealing with rural populations and is kind of a man of the people, but he had 00:46:00never been--I don't know if he had ever been overseas, and he had certainly never been to Africa, but he just took to it like a duck to water. Really had a great rapport with people and was very positive and kind of unflappable, just never seemed to let things get to him too much but was always right there and, like every other EIS officer, working incredibly long hours and very hard to get the information out. When I got there, he had been with some other people before, and one of the things that they had been working on was a community in--I can't remember the name of the district, but it was actually a mining district, or a district with a lot of mining, and they had a community there [Mawah Village] that had been hit by a number of cases, and so the community decided to self-quarantine. There was a local doctor there who was Liberian but his father had been an epidemiologist, and he had a good public health sense, so he worked with the community to convince them that they needed to self-isolate, 00:47:00self-quarantine. They had a lot of cross-river boat traffic with another community, and then obviously they had a road in and out. So they organized themselves, and the doctor provided health care to people. They basically stopped their markets, and they chained up--they actually literally chained up their canoes so that nobody could cross over, but they made allowances that they would allow some of the farmers who had plots on the other side of the river to go during certain times of the day, but they really monitored them. And they stopped transmission. They had no more cases after a certain time. So David had told me all about this, and I encouraged him to write it up. At that point there had been a lot of negative controversy about the forced quarantines that were happening in Monrovia, but here was an example of a community that chose to do it themselves, and it had been effective, and they were able to get the support they needed to make it effective, and I thought that lesson was needed--needed to get out there and say if the community chooses this and has the right kind of 00:48:00support, this could be an effective way to stop transmission. So he started working on that.

The other thing that was going on in Bong that became important for me was there was a stadium that had been set up where the county decided to set up an iso[lation center]--like a quarantine unit. People who had been exposed could come and stay there for their twenty-one-day monitoring period before either they were let out to go home or went into an ETU. And it had not been run well. There was a lot of people staying in these UNICEF tents, but they didn't have food and water, and there was no medical care, and they were pretty miserable. So some of the people who had been there before with David were intent on trying to close it. And David had done a great job of finding a nurse who would come out and sort of triage all the people and make sure that they weren't symptomatic, and he was trying to get them released to go home. That was our first mission, was let's close this place.

But then we got involved in this outbreak, which I'll tell you about in a 00:49:00second, in this town of [name withheld], which was a long way away--a long way away. Several families had come out of this community, walked out and made it to Bong. And they had been exposed. They had actually carried out the mother of this family who had died of Ebola, and so they were all terribly exposed, and they had no place to stay, and they were so far away from their home that there was no way we could send them back to do their quarantine period back home. So it became clear that actually, you know what? We need a place where they can stay safely and be monitored and be close to an ETU so if they do develop symptoms, we can whisk them away and get them the treatment and hopefully save their lives. So instead of closing this place, we ended up starting to support the place. The idea of facility quarantine, of well-managed facility quarantine under certain circumstances became something that we started doing in Liberia. I 00:50:00can't say CDC came up with this idea and promoted it, it was sort of happening organically. But at first we were against it and then realized that done correctly, this was a pretty important tool. So we worked with the county. They ended up having some nurses come back from training, from infection prevention and control training, who could help triage the community members who were staying in this. We got an additional tent. They were able to start managing it properly, got food and water. We continued to advocate for resources, but it was mostly a county-run enterprise, which was remarkable given how poor this county was. But they poured a lot of resources into it, and eventually this family who came out, the father became sick. He probably still hid his symptoms from us for a couple of days, wasn't willing to acknowledge that he was sick, but finally it 00:51:00became clear and he was removed to the ETU. But none of the rest of his family became sick, and he survived. He was able to eventually go and get his family and take them home.

But because of him coming out from [name withheld], which was in the county of [name withheld], which bordered Bong, and there was another group--kind of a separate group coming out of [name withheld] as well around the same time--who became cases, it became clear that something was going on in [name withheld] County where CDC did not have a presence. It was so remote. Even though it was physically close to where we were in Gbarnga town in Bong County, the only road into [name withheld] would have gone more into Monrovia. So we had to take a back way and cross rivers to get there. So David Blackley and Matt [Matthew] Westercamp and John [C.] Neatherlin decided to go in and take a look and see 00:52:00what was going on. They went in, I want to say it was October 31st. Somewhere around Halloween--no, that was another night. But it was around the end of October. They made this huge trek into [name withheld], walking for hours. You first drive three hours until you get to the river, and then you cross the river in a canoe, and we had Sampson, our Peace Corps community liaison, like most Africans, can't swim, so he was terrified to cross this river in a boat. So they got him a tire, an inner-tube, and put it around his middle, and he sat in that in the canoe to go across. Very brave man to do that. And then they walked for hours, and they got to this first community and spent several hours talking to them about Ebola and walked on to this even farther community of [name withheld], arriving almost at night, and ended up--I think there were six or 00:53:00seven people--actually there were some local--there was somebody from an NGO who accompanied them, and then like a local guide. There were six or seven people, and they all ended up sleeping in this one-room house. They said that they asked for some dinner, and somebody brought them like some chicken stew, and it was just one bowl and one spoon. They were six very, very hungry people all staring down at the bowl, saying, hmm. So they fell asleep with a lot of hunger.

They ended up finding that there were two men--who they couldn't relate to this family who came out with the wife who died--but two men who had recently died in the village. One of them supposedly died after a fall from a tree, and the other one--I can't remember what they initially told us he had died from. But only one of them seemed vaguely suspicious of Ebola, because he had a son who died before. But the timings that we were given and the lack of connections to the 00:54:00other cases--when the three of them came out later, we assessed it and thought it just doesn't sound like Ebola. So we didn't do anything, and then two days later we heard from the public health office in Bong that the families of those two men had come out. In one family it was a mother and three kids, and the other was a mother and two kids, and they were all positive. All of them went to the lab, and they were all positive, and I think out of all of those seven people, five died. We felt blindsided. John and Matt and David had sat in a room as close as you and I are to these two wives and looked them in the eye, and they never admitted any symptoms. I think they were in denial about what had 00:55:00happened to their husbands. And we felt very sad, that if we had known, we could have encouraged them to walk out and to get--at least to be closer to treatment, and maybe they would have had a better chance of survival.

Then it became clear that there was a big outbreak going on in [name withheld], and we needed to mobilize to get back there. We went back to Monrovia to try and gather equipment because this place was so remote that we were going to need to go in with equipment. CDC doesn't do treatment and care, so one of the organizations that does, Samaritan's Purse, agreed to go in and set up a no-touch care facility. Logistics just took too long, and this was a lesson that we learned from this outbreak. It took us another--I want to say week before we could get back in. We were delayed a couple of times. At that point, we were hoping the US military helicopters could take people in because that would be 00:56:00the quickest way to get there and the quickest way to get back. It took a few days to arrange that with the DoD [Department of Defense], and then in the end they said they would only drop us off, they wouldn't pick anybody up. And Samaritan's Purse, getting them organized to be able to go in was taking a few days, and meanwhile we were hearing of more and more people who were coming out of this community and positive, some of them making it and some of them not making it.

We finally got their permission to go and got the helicopter transport, and so I went back with David and Matt Westercamp, and the military flew us in a Black Hawk into the community. By that time we had enough--we knew people--David and Matt had made contacts in the community. We were able to pass the information that we were coming and that we were coming by helicopter, so that we wouldn't scare them. The military was able to find an appropriate landing site in a football field in the lower part of the village so that we weren't going to destroy houses or anything. I had never been in a helicopter before. This was 00:57:00pretty momentous. We went with Frank [J.] Mahoney and Athalia [S.] Christie and Frank [Francis] Kateh, who was one of the leaders of the Liberian response. We flew into this village, and the [US] military were totally freaked out. They were--when we got off the plane, the whole village, of course, had never seen a helicopter. Everyone was down surrounding the football field, and one of the Marines, or whoever it was flying the helicopter, asked me, "Are these people--are they going to hurt us?" [laughs] "No, they're not. They're happy that we're here. They want help."

Frank Mahoney had the foresight to bring a huge bag of rice, and we brought all our stuff out and went and had a big community meeting, talked about what was going on, what was happening, and that we were there to help and that three of us were going to stay on, and of course we were explaining what Ebola was, we 00:58:00went through all of this. Frank Kateh is a great speaker and helped explain to everybody what was happening. Then we started asking about cases. We told the community that we wanted to find out about anybody who was currently sick and that we were going to do a door-to-door mapping and sort of census-taking. Then we were going to have to deal with the houses where people who had been living who had gotten sick and left. We were going to have to decontaminate the houses. We had brought chlorine with us.

Frank Mahoney and Athalia Christie were getting ready to leave, and all of a sudden I realized I don't actually know--we've got one woman who is actively sick, who appears to be sick. The helicopter would not take her out. She was too sick to walk, and it turned out that the community had no latrine--not a single latrine, and it was a community of about eight hundred people. So I ran to Frank Mahoney, and I said, "I don't know what to do with this woman, if she is 00:59:00having--" as they said, toilet, "If she's going to have to toilet in the bushes, then that's going to risk transmission. What do I do?" And he said, "Well, get a bucket and fill it up about, you know, two inches of chlorine in the bottom, and have her use that as her toilet."

The helicopter takes off, and Matt and David and I separate. There were two community tracers in the community--health volunteers who were doing the contract tracing--in the community, and they went off with us. There were also some members of the--some people had been trained in safe burials, so we had some trained people, we had some equipment, and so we divided up. Matt went and did the household census, went around mapping all the houses and identifying who lived where. David went and did the case investigations for all the cases that could be identified that had come out of the village, and try and link up their exposures and figure out the chain of transmission, and using that to make sure 01:00:00we weren't missing any other cases. We went and talked to the two who were in the village right then who were currently feeling ill. One of them was [name withheld], and the other was an old man. [Name withheld] was a mother of two, and her husband was there. She turned out to be the sister of one of the two gentlemen who died whose wives had come out and were all positive, and we knew she was sick. We knew that she clearly had Ebola. She was still able to talk, and we had to give her the bucket with the chlorine and explain that it was very important that she stay in the very close environs of her house, that her children and her husband needed to move out, that nobody should be touching her. We were waiting for Samaritan's Purse to come. They were supposed to come the next day and set up this care facility, so we were reassuring them [the patient 01:01:00and her family] that somebody would be coming, but in the interim nobody should be touching her. She was still able to move around. And then we realized, okay, but now we've got this waste. What are we going to do with it? We had our slide set from our orientation, and I've been in public health at this point for almost twenty years, but I had never dug a pit latrine before. [laughs] One of the skills I always thought that schools of public health should teach, like there should just be a plot of land and everyone should go out and learn how to dig a proper pit latrine, one of those basic public health activities. We knew how big it needed to be, and we told the community, we need you to help do some things that are going to protect your community. So we got some guys and told them how big--figured out where would be the right location in the community to dig this pit latrine. It wasn't really going to be a latrine, it was going to be a disposal pit, and they started digging. And so they ended up--by the end of 01:02:00that day, they had dug like a four-foot deep hole. It was about a meter by a meter in the ground. And I went around with the guys who had been trained in safe burials, and we first reviewed all the procedures for putting on and taking off PPE [personal protective equipment] and show that we made up our chlorine solution and again using the little slide set that we had from orientation, so we made up this disinfecting solution, and we had sprayers with us. So we went to all of the houses where people [who had tested positive for Ebola] had been living, and we pulled out all of their bedding and anything else in the house, and the sprayers went in and sprayed it all down with chlorine. Now, I know now--well, I even knew it then, too, that by this time it had been days. There was really very little chance that there was anything that was truly infectious in the house by that point. It would have dried up, and the virus was no longer viable. But that said, you don't want to take any chances, and there is 01:03:00something psychological about it, important for people, too, to feel that things had been cleaned. So we went to all of those houses, and the guys sprayed them all down, and I was the monitor watching to make sure that they were taking the safety precautions and that they were following all the donning and doffing of the PPE correctly. Then we had some mattresses, and at that point in Monrovia, they were burning mattresses of people who had been sick. We were out in a village. We have--there was almost no fuel there. People had a little bit of kerosene, but we can't find enough fuel, and these are huge foam mattresses, so we were like, what do we do? How do we handle this huge foam mattress? Like, would it even be safe to burn it? We could end up burning down this village. In the end we just decided we were just going to spray the heck out of it with chlorine and just soak it with as much chlorine as we could, and so we just literally sprayed the heck out of all the mattresses and left them out in the sun to dry and told the people not to touch them, and we said it would be better 01:04:00if you never used these again, but knowing that people in these poor villages are unlikely to do that, but also feeling confident that it was going to be okay.

We kept looking in on [name withheld], who progressively declined. We had oral rehydration solution, so we were able to give her that, and we had nothing else. I mean, we were not supposed to be treating. We thought Samaritan's Purse was coming the next day, so we just kept going by [her house]. We made sure that her husband wasn't going in, and it was horrible. I can still see her, sitting at the--her house opens onto the back of another house, and there was a bench there, and she was just sitting out there on the bench, or sometimes she had a mat, and she was sitting outside, and people were gathered around her but not 01:05:00touching her, not right on top of her, and it was just like a death watch. Every time we would go by, she would basically be collapsing more and more. In the meantime, though, there was another gentleman who also was sick, but not as bad, and he was the uncle of one of the men who had died. He had a wife, and we could not get his wife to move out, she refused. But they had rooms that didn't open onto each other, that opened onto the outside, and so they weren't necessarily staying together. We couldn't make her--there was a third woman who was a suspect case, too, and she seemed well enough that we suggested she walk out. She ended up walking out to Bong and getting tested and was negative, so that was good. But then we had the waste from these two people who were sick, and we had to go around and collect the buckets in the morning, and the guys who were in the safe burial team all dressed up in their PPE, and I would follow them, and so they'd first spray the bucket down as well as they could with chlorine, 01:06:00and then they'd pick it up and walk it down to the waste pit, pour it in, and then we would douse it [the waste] with kerosene and then burn it. And I remember thinking as they poured this bucket of fecal material into it, like, that's a bucket of Ebola right there, going into this pit.

Q: Just to clarify, what was it that they were burning? The kerosene in the bucket, or the latrine?

LINDBLADE: We would throw the kerosene down into the pit and try and burn the solid waste.

Q: I understand, okay.

LINDBLADE: We were sleeping in the church. They gave us the church, and we sprayed it down with disinfectant. We didn't really need to, but at that time you're totally amped up, and you just want to make sure that you could feel comfortable, so we asked that nobody else would come in and that it just be a place where we would sleep, and they were respectful of that. But there were some weird tensions in the village. You know, there's no [tele]communications 01:07:00from the village. People would walk up to this hill. They would take a half an hour walk up to a hill, and there they could get signal, and then they would call to people in Bong County or Gbarnga town, and that's how they could talk to people. At one point, we were sitting on the porch at this church, and a big group came down from the top of the hill, and they were wailing and upset, and it turned out that one of those people who had walked out previously had died [from Ebola]. People were very upset, and there was a lot of crying in the village and wailing, and then we were up on a hill in this church, and we could see what they called the palaver hut, where they met, and the palaver hut--lots of people kind of roiling around. So we would go down and talk to them again, and it would be again a big community meeting. We couldn't understand the local language, and events that happened later make me think that it's probably a good thing. We were able to calm them down and talk to them and try to explain what 01:08:00was happening, but we didn't feel--I mean, I felt like this was a little dicey, but I never felt afraid. The only time I felt a little worried was one time when that group came down the mountain and told us that one of their relatives had died. There was a man standing with a panga, a big machete, and I was sitting on the edge of the porch, kind of next to him, and I thought, I'm just going to back up a little bit here. But that was the only time I felt at all concerned. But there was--there was definitely a sense that we had to continue to talk and discuss things so that they understood. At that point, we had also realized that things were moving too slow--it had taken us too long to get there, it was taking Samaritan's Purse too long to get there--and that anybody who could--who was exposed, who was a contact, should go and walk to--at least walk to the river cross[ing], and that we would arrange for ambulances on the other side--we had satellite phone communication--arrange for ambulances to come and take them 01:09:00to the stadium to wait out their twenty-one days. That if they became sick like [name withheld] while they were in the village, they were never going to get out. There was a lot of concern from the community about this, and we had to go back and forth with them so they could understand why we were recommending this. And again, one person did eventually go to do that, but [name withheld] couldn't make it. The community chief was younger and was really on our side, but there were some older people in the village who were not very happy with all of this, so that's one of the dynamics that were going on in the background, and there were other dynamics that we didn't understand at the time, either.

We had a hard exit. We had to leave because [one of the team] had to be on a flight, and we probably should have had four people so that two could walk out and two stay. But for safety reasons, we couldn't have him walk out alone, and we couldn't leave one person behind, so we all had to go. Samaritan's Purse 01:10:00showed up. It turns out that their helicopter was too big to land in the village, and so they had landed, the night before, several hours away, walking. So they came the next day, eventually, walking in. But it turns out they really had very minimal equipment and really were not doing much more than we were able to do, except that they could set up isolation tents that people could go and stay in. But we had to go, and so we tried to pass on all of our information to them as quickly as possible. By that point we had listed everyone in the village, we had every potential suspect case, we had all of the contacts that needed to be monitored, and then we had [name withheld] and this other gentleman that we suspected had Ebola. Just within an hour after Samaritan's Purse arrived, we heard this huge wailing coming from the village, and we knew [name withheld] had died. So we waited a little bit, and then we all went down, and her husband, [name withheld], was sitting on the bench, and her daughter was 01:11:00crying. [tearful] And we paid our respects to [name withheld], and we told him how sorry we were. I just remember thinking about that little girl. You know, Africans don't show a lot of emotion, but she was crying--crying quietly on her own there. But I also, at the same time, felt very good that we had saved her. We didn't know for sure if we had at that point, but the fact that the family moved out before she [the patient] died gave her a really good chance of not being infected, and in fact, in the end, [name withheld] was the last case in the--well, maybe that's not true. The old gentleman, whose name was [name withheld], he turned out to be positive but recovered on his own in the village. And then it turned out there was one other gentleman that we didn't even suspect at the time but who turned out to be positive, too, who also survived in the village. But there were no more cases after that. The whole thing [outbreak] 01:12:00ended. So, yeah, I felt like we had done a good thing, that we had at least prevented that family from--those kids and her [the patient's] husband from getting sick. So we left and walked three hours, a beautiful walk, actually, through the forest and got to the river, and the canoe came across and took us to the other side where Sampson and David were waiting for us, and we rode back to town, and then eventually the next day got a helicopter transport from the UN [United Nations] back to Monrovia. And then I took a different role and started coordinating the county teams [from] there [Monrovia].

Q: Can I ask, were you--or who was it who was doing most of the communication with [name withheld]?

LINDBLADE: All three of us. We would all--we were doing different things in the village, so all of us would take--I mean, we would all--every time we would go 01:13:00by her house, we would stop off and talk to her. She didn't understand English, though, so like we would talk to her. I don't know how much she understood, but--yeah, there was not much we could say.

Q: Yeah, I can't imagine it's easy to deliver the message, "No one can touch you, and your family has to leave."

LINDBLADE: Yeah. [pauses] There was a little boy at the time who was from a different family, but while we were going door-to-door, at some point we were there with him, and he just started vomiting on the ground. It was like, oh my God. It's unusual for children to become sick without a parent ill, because they [children] just don't--they're not [normally] touching sick people. It was a 01:14:00very--from our discussions with people, it was very difficult for us to make the case that he may be infected. Like, he had played with the son of somebody, but it was just not--there wasn't a very strong [epidemiologic] case [for him to be infected]. He turned out to be negative, but for a while we were quite concerned and watching him. Again, having a small child, you can't tell the parents not to touch them, but we were trying to limit the number of people who would be touching him and who would be potentially exposed, and certainly [asking them to] let us know when he did vomit so we could come and kind of disinfect the vomitus and try and keep them protected, but there's not much you can do in a rural village setting like that. My experience with that kind of set a couple of things, like this idea that we needed a place where people from remote areas could go and stay safely until we knew that they were out of their incubation period [and uninfected]. And then the idea, too, that we cannot intervene 01:15:00quickly enough in those communities. We have to do everything we can to get them [exposed people] out [of the village and into an ETU]. That is the first intervention. As soon as you know that there are cases in a community and that you've got high-risk contacts, you need to get them out. That became the modus operandi for subsequent outbreaks, as we tried to pass that message on. There were a couple of cases--well, one--two additional communities where Medecins Sans Frontieres went in and set up an isolation unit there because there was either resistance to leaving or too many cases already who couldn't walk out. But most of the rest of the outbreaks, we started hearing about things quicker and sooner, and we were able to get in there early enough that we were able to get people out and stop outbreaks pretty quickly.

Q: Was it pretty soon that you started calling that the RITE [Rapid Isolation and Treatment of Ebola] strategy?

LINDBLADE: Yeah, well the RITE strategy was actually more about getting 01:16:00organizations like Samaritan's Purse and MSF [Medecins Sans Frontieres] into the communities.

Q: Oh!

LINDBLADE: It was rapid response. The initial idea was moving resources in. For example, in some communities that were being affected, it was if they need clean water, trying to mobilize UNICEF to help them with clean water or address community needs. But RITE kept getting more and more rapid, and that meant less and less intervention [in the villages]. So it evolved. It was already underway before that, and that's why Samaritan's Purse was part of it [in the town we visited], but it [RITE] just became more and more pared down. We just realized that the best--no matter how fast you can deploy helicopters and teams, there is still going to be a delay of a day or two, and there's just no delaying. Like, 01:17:00same day. You go in, you find somebody who's sick, and you get them out [to an ETU]. You try and get out all the cases immediately, and then you monitor the contacts.

Q: That's the importance of speed.

LINDBLADE: Yeah. I mean, if we had been able to--I don't know if people could have accepted leaving by helicopter, but in a couple of those in Quewein, which happened later, I think if we had been able to get people on transport and take them to ETUs right away, then we would have stopped a lot of transmission.

Q: So how long were you in Bong County?

LINDBLADE: I think somewhere between two and three weeks.

Q: And then down to Monrovia after that?

LINDBLADE: And then Josh had to leave, and so they needed somebody to come up to Monrovia. I was really torn because at that time I was completely emotionally invested in Bong [County]. Although, actually [name withheld], I was already in Monrovia when that [investigation and response] happened. I had already left 01:18:00Bong, so I ended up doing that outbreak from Monrovia as opposed to from Bong.

Q: How long were you in [name withheld]?

LINDBLADE: We stayed there.

Q: An intense two nights. [laughs]

LINDBLADE: Yeah. I was alluding to what happened later. So, Samaritan's Purse went in and set up their isolation unit and then made at least what appeared [later] to be a mistake. They left [the village to get more provisions]. At that point, they didn't have any cases in the community, because we were still just monitoring contacts at that point, because [name withheld] had died and the old gentleman was just hanging in there. We had had the International Medical Corps--it would be terrible if I'm getting this wrong--the group that was in the ETU [in Gbarnga town]. They had flown in some people to take blood, so that's how we ended up knowing for sure that we had a postmortem sample on [name withheld, who tested positive]. And then a bunch of other people were tested, 01:19:00and that's how we found for sure that the old guy was positive, and then this other man who we didn't even know had really been sick, he had admitted to a little bit of past symptoms, but he clearly was not a terribly ill person. He had also not admitted to any contact with the cases. So we were really shocked that he ended up testing positive, that he was. Those were two clear examples of people who had gotten Ebola and survived it on their own without medical treatment. That was also surprising because at that point everyone kind of assumed that you get Ebola, and if you don't get medical treatment, you're going to die, but these guys had recovered on their own. So Samaritan's Purse left for a few days, and one of the women that we had been working with who was one of our contact tracers turned out to have a husband who was what they call a 'black-bagger.' He was an untrained medical person, or maybe he had some very minor training. He was the one [person that] people went to for medical 01:20:00treatment in the village, and this happened throughout a lot of the Ebola epidemic, that he [and other black-baggers] felt very threatened by the teams coming in, that we were trying to take away his business. Apparently they were--even though his wife was on this contact tracing team, they were working both sides and agitating with the community against the response effort. So when Samaritan's Purse went back after being away for a few days, the community had broken into the supplies that had been left behind, and they were misinterpreting what was there and--I don't remember exactly what it was, but there was some kind of [oral rehydration] solution or something in--and so this quack doctor was saying that they were bringing in poison and that they were going to kill the population, they were agitating. And so there was a real division in the community about this. The community leader, who we had worked with, was still very reasonable and trying to say no, this isn't the case. But the rest of the community was hyped up on these misleading ideas, and when 01:21:00Samaritan's Purse came back in, they went in with somebody who was a local--who spoke the language, and he could hear what everyone was saying, and [he could hear] there were death threats against them. It could have been happening to us, too, but we just didn't know. So they got very worried and ended up having to evacuate, calling in their helicopter, and literally running for the helicopter with an angry mob behind them. And then nobody was allowed to go back to [name withheld] for a few days. We ended up mobilizing a Paramount Chief. The chief system is really strong in Liberia. The Paramount Chief for that area actually was an old, old man and lived in Monrovia, but one of the local NGOs was able to find him, and they drove him all the way up. He walked in, this old man walked into the community and spent several days with them, essentially trying to explain and work it through with them. And we received the most heartbreaking letter from the village chief saying to CDC and Samaritan's Purse, please some 01:22:00back, we're dying. We knew at that point it was safe, and so two--Satish Pillai and Laura Broyles, went back [into the town] from CDC, and some other people from different NGOs walked back in--this was about a week or ten days later. The community welcomed them and was very grateful for them to come back, and they went around and reassessed everybody and checked on all the contacts, and by that point we were well into the twenty-one-day post-exposure period. And, you know, you pretty much get your cases within the first fifteen days, and after that if people are okay, they're not going to get sick, really, even though we carry it out to twenty-one days. So they assessed everybody. They went to every single person and took their temperature and checked on them, and nobody was sick, and that was kind of the official conclusion of the outbreak.

Q: So when he says, "Please come back, we're dying," had there been more transmission going on?

LINDBLADE: No, at that point, there had not been more Ebola cases, but I think 01:23:00he was--they were still in their incubation period, so they were all still very worried. They didn't understand all of this exactly, but they felt--they ended up having--I have the actual numbers, but the mortality rate of the cases in [name withheld] was something like 70%, so I think there were like twenty-three [twenty-two] cases total, and I think seventeen [sixteen] of them died.

Q: That's wild.

LINDBLADE: Yeah, from a small village.

Q: Can you describe any of the Liberian people you worked with in Bong County who really stand out to you in your memory?

LINDBLADE: Yeah. Emmanuel Dweh, who was the surveillance officer, a tall, thin guy in his early--mid--late thirties, early forties. He was a little bit reluctant at first. I think he had a lot of--you know, they're government 01:24:00employees. They're not paid routinely. They were facing a lot of personal challenges in the midst of his biggest professional challenge ever. But Ebola for us was this huge, catastrophic thing, and in many people's lives it was yet another catastrophic thing. They face a lot [of problems] there [in Liberia]. So, for Emmanuel, when we first got there, I think he was--you know, CDC had been rotating people through, we were not the first group there. I think he was a little bit tired. He was not only battling Ebola but a measles outbreak. I mean, there was a lot other stuff going on. And so at first, I think he was a little--didn't seem to be very active. But then when we went around with him to all of these districts, he saw us stand up and talk to people, and he became more confident standing up and talking to people. He started saying things like, "Look at who these white people are who've come here. They've come here because 01:25:00they care about you, and they want this disease to stop. So you need to step up now and help make sure that Ebola stops. It's up to you." And that was kind of our message, was trying to empower them to say, you guys have the--you actually have the tools. We know what to do. If you do these things that we're asking you to do, we'll be able to stop Ebola, but it's up to you. You are going to be able to protect your community. He took on that message, and he really became this dynamic, very effective leader over a couple of weeks, and I felt, again, the power of CDC to be able to give somebody their voice and their tools, and he was able to run with it and feel much more confident and very active. I still email him--well, we've coauthored some papers, and he wrote to me the other day. I hope that he's able to get into some of these programs like the FETP [Field 01:26:00Epidemiology Training Program] and really expand his skill set because he's got tremendous potential.

Another person was Sampson, who was part of the Peace Corps team, and he had just previously--I can't remember what he worked on, like cookstove program or something, nothing health related, and again was just inspired by all of the--we were inspired by him, but he was taking a lot from the CDC teams. He didn't know much about health to begin with, and he didn't know anything about Ebola, but after being with all the CDC [personnel] and hearing the stuff that we were saying, it got to the point where we didn't even need to stand up in front of the community. Sampson would just get up and knew exactly what to say and how to say it, and of course he had the vernacular, and he knew how to talk to people, being able to express things in the right way and use the right analogies and anecdotes to illustrate points. That's a skill that Africans have that's wonderful, and so he would always be able to pull out a story of something and relate it to what was going on and help people make those connections. And 01:27:00seeing him--seeing the pictures of him getting in his inner-tube into this canoe and crossing this river and knowing that he was literally terrified of the water but doing it because he wanted to help his country was really, really remarkable. Yeah. They were really, really good people.

Q: So you come back to Monrovia, and what does your work in Monrovia entail?

LINDBLADE: It was to coordinate all the--so we had people in, I don't know, nine of the fifteen counties at that point, so it was to coordinate their activities, supervise them even though I wasn't able to see all of them in the field, but make sure that they understood--orient them when they came in and make sure that they understood what was needed out in the field and what they should look for. These people were coming from all sorts of backgrounds. Some had had extensive African experience, and some people had never done anything. People were coming from non--had just not worked overseas, or if they had it had been at the 01:28:00ministerial level and not down on the ground. So just making sure that they had the skills that they needed and understood what their role was going to be and how to present themselves and that we were there to support the Ministry [of Health and Social Welfare]. One of the things that I really like about CDC is that we took a very low-key approach. We didn't have jackets that had CDC logos emblazoned on them. We didn't have CDC t-shirts. We were there to support the Ministry and to make sure that they were--that they had the tools and the information that they needed. I went to help on a couple of outbreaks during that time as well to, again, bolster the people out in the field and that they knew what the right things were to do. We started this inventory of the contact tracing. We started--you know, Monrovia became a big deal [in terms of the number of Ebola cases], but Michael [J.] Beach was there, who was working with the Monrovia group, so all I needed to do was be somebody for him to vent to. 01:29:00Because he was--he's just amazing. He was working in Monrovia, which was such a complex kind of situation to be in. I knew the rural setting, but I didn't know Monrovia very well, so Michael just ran with that. And then starting training materials. Starting to recognize that there are some big gaps here, that we do not have standardized case investigation and contact tracing [protocols or training materials]. I also didn't like how they--in some of the counties they had separated the case investigation from the contact tracing, and I once went out with the team from Margibi County, who had completely separate [case investigation and contact tracing] teams. We spent hours just trying to trace contacts of a case, and because it wasn't--you know, it needed to be integrated so that the people who were going out to do the contact monitoring were there when the case was investigated, so they know where the person lives and who the contacts are and what the situation is. It just was so inefficient, and they would lose days of monitoring because of this lack of communication. We were also trying to change that and make sure that [case investigation and contact 01:30:00tracing activities in the] counties were more integrated. We also had two calls during the week that were specifically related to the field people [i.e., CDC staff working outside of Monrovia]. One was the Wednesday call when the field people would tell us what they were doing, and we would get updates from the different counties about the epidemiologic situation. We tried to standardize the slide set for that to a certain extent so that we got the information we needed from the counties. But then we started Sunday calls, which were more discussion. The people in the field were really eager for more information about what was going on, and there were lots of issues that would pop up, and they didn't know what's the CDC guidance on this or policy about it or thinking on this issue. So we would bring in different people to talk about what was going on with safe burials or what was going on with home protection kits or just different topics. That was really fun because it gave us a chance to be technical, to think about these technical issues and make sure that everyone was on the same page about the CDC guidance.

Then towards the very end, my replacement ended up coming. I extended [my time 01:31:00in Liberia] but started to look at some of the data on these outbreaks that we had and was trying to summarize it. Not me, somebody else was supposed to write it up. But there were just too many outbreaks, and we didn't want to end up sending an MMWR [Morbidity and Mortality Weekly Report] of twelve different outbreaks [that is, twelve articles on different outbreaks]. Clearly there was enough commonality [between outbreaks] that we needed to just do one [report], and somebody else was supposed to do it, but eventually it just kind of fell on my lap. So when I was looking across these twelve outbreaks, it was really interesting starting to plot the time it took us to hear about it [i.e., how long before we were notified that the outbreak had started], the time it took us to respond, and then the time till the last case occurred, and plotting that over time. The first time I did it, I looked at it and I was like, holy cow. It's this really nice declining trend that we're hearing about them faster, we're responding faster, and they're resolving faster. It was basically because of this RITE approach that we were hitting them [the outbreaks] really hard and 01:32:00quick and trying to get people out [of the communities and into ETUs], that we were actually seeing results. Working up that data and being able to present it, and then eventually to write some papers out of it, was what I did during most of my last week or two. And then Dr. [Thomas R.] Frieden visited, so I was helping plan that visit.

Q: Can I ask, doing the academic looking at the data, etcetera, is a lot different from what you had done before. Was it difficult to make that transition?

LINDBLADE: No, because it's kind of my work. I go between my SAS [a computer program to analyze epidemiological data] screen and being out in the field. I like having both. I like having the analytical part and the more hands-on part. Although normally my hands-on [work] is not disinfecting toilet buckets, but instead designing studies and helping implement research studies. But still, I 01:33:00like to do the analytical part, too.

Q: Was putting out like the MMWR, for instance, was that helpful to the response?

LINDBLADE: I don't know that it was helpful to the response--I mean we already--everything that was underway was already underway, whether or not we put out an MMWR. But I think it helped crystalize the ideas, it helped show impact. It was reassuring that we could show that we're getting better at this, we have validation of the strategy that we're using. And Monrovia is going to continue to be a problem for a while. There's a different strategy needed for Monrovia, but for these rural outbreaks that flare up--and they're seeded from Monrovia, which was also important to know that over time, transmission was starting to centralize in Monrovia, and that [increase in cases in Monrovia] that was sparking these outbreaks. But they weren't transmission coming from somewhere else; [that is, the outbreaks occurring from rural areas weren't linked to unknown transmission chains]. We weren't missing something. That 01:34:00information was important. But just, yeah, knowing that we could continue to put out these flare-ups while we focused most of our attention on Monrovia, and as long as we did that, those flare-ups were unlikely to continue on out there. And it wasn't just the RITE strategy. There were so many things happening at the same time. The ETU standing up and being able to have enough beds where people could be isolated [and treated] was huge.

Some of our later analyses show that if you can get somebody out of the community before they die, it doesn't even matter if they're in their terminal illness, if you can isolate them before they die, you've essentially stopped transmission; that the transmission that's around the person being ill is just not enough to sustain onward transmission. It's really something about the death itself. It could be because they're more viremic; it could be because there's just much more touching at that time; it could be because there are more people touching at that time. Whatever it is, it's [the transmission] around that death 01:35:00period, and so getting them out before they die is what stops transmission. And that was happening more and more just because of the more efficient ambulance systems and the more efficient ETUs and surveillance that was going on. So all of that was happening in the background, and I know all of our people were working really hard at making those systems work from the central level, and that background was absolutely essential. Nothing that we did on those outbreaks would have worked if that essential infrastructure hadn't been in place.

Q: Can you tell me about having Dr. Frieden come into Liberia and talking with him, some of your conversations?

LINDBLADE: We didn't--so I went up to Bong, I was the site officer for Bong, and we decided to highlight Bong because we could go to an ETU, we could go to a lab, and we could talk to the county health office there. In fact, the EOC [emergency operations center] had just been set up in Bong County, like literally the morning he arrived, they were moving the furniture in. So we thought this was a nice chance for him to see a lot of things in a very short 01:36:00amount of time. I was already up there when he and the team landed, and we were whisked off first to the ETU, which was, I think, incredibly moving for him. It was a very well-run ETU, one of the best--just really, really solid. And he got to talk to a woman who was there with her baby, and the baby--the mother had been positive and had left the baby at home [when she entered the ETU for treatment], [she survived and] went home, and it's not really clear when the baby became infected, but she [the baby] became sick, and she was one of the youngest children to survive. She was only--I can't remember if she was six or nine months old, but she was still an infant. There was a place set up where you could talk to patients who were in the ETU, and so she [the mother] came down with her daughter, and Dr. Frieden spoke to her privately for a while, and I think we were all moved by her story and talking to the folks at the ETU, the doctors, they were just ecstatic. They had seen so many people die that for them 01:37:00to see this little baby survive was just incredible. Then we went to the graveyard at the ETU, and I had at that point been spending a lot of time working on the transmission diagrams for these different outbreaks, and many of them happened around Bong. So Gbarpolu, Tayla-ta, Quewein, and Bomota, all of these outbreaks had happened and those patients had gone to the Bong ETU. I knew their names because I had been pouring over the data, and I get to the cemetery, and some of those names were there. So that was also really moving. Like I didn't know that person [personally], but I knew that person [from the data], and I knew kind of their story with us. So that was very hard. Dr. Frieden spent some good time there, and then we went to the [US Navy] lab [at Cuttington University] where we had to unfortunately rush him through--I mean, we had such a tight schedule. But he got to see this--it's such a small lab, it was amazing. They had two little plastic hoods [plastic boxes to prevent the virus from 01:38:00contaminating the environment], I mean like half a meter by half a meter in there, and that's where they were doing all these diagnostics, or at least decontaminating and extracting the nuclear material and then testing, and they were doing incredible jobs. The Navy guys were there. They were staying for like three months. They were just, you know, eighteen hours at the lab every day--every day--for three months at a time doing amazing, amazing stuff. So we toured that, and then we went back to the county health office and got to meet with the county health officer, and I was able to stand up and tell Dr. Frieden what amazing partners they had been. We were working with WHO there, and WHO had been a full partner. It was such a great working relationship. It was really very special. We felt like we had a very equal relationship, and we were able to give, and we were able to learn from them and them from us. It was a great partnership, and I felt very proud that I was able to show that to our director 01:39:00and also for them to receive a visit of our director. And I was able to make sure that Sampson and David, our team, got a picture with Frieden, and they were very happy with that. And then we took off, and we flew--I got my second ride in a Black Hawk helicopter back to Monrovia. It was quite a day.

Q: Before we move on from Liberia, any other memories that stand out?

LINDBLADE: Well, there's the--the office that CDC used at the time was an old embassy that's right on the coast. There's a guard post there that sometimes when we were feeling a little stressed, we would go and sit on the guard post and just look at the ocean out there, and it was just a really amazingly beautiful setting. Just being grateful for the chance to be there and to help 01:40:00and to have all the experiences that we were having was really--I felt very grateful for it.

Q: Should we take a break, or are you good to continue?

LINDBLADE: I think I'm good. What time are we?

Q: It's 11:15, about.

LINDBLADE: Okay, we can go ahead. That's fine.

Q: Okay. When is your lunch appointment?

LINDBLADE: It's at 12:00.

Q: Okay. This is amazing listening to you, by the way.

LINDBLADE: It's very cathartic.

Q: Good, I'm glad. So what--did you spend some time back in Atlanta after--or in Thailand? Excuse me.

LINDBLADE: Yeah, I left right before Christmas, so I was back in Thailand for--Thailand has been very serious about their surveillance and monitoring of anyone coming back from infected countries. You fly into the airport, and you have to go to the health desk and self-report, and then they drive you home 01:41:00[laughs]--the Ministry of Health drives you back to your place so they know where you live, and then they call you every day for twenty-one days. But they're so funny. They call you up in the morning, and they say, "Hello, is this Kim?" "Yes, this is she." "How are you?" "I'm fine, thank you." "Okay, goodbye," and they hang up. [laughter] We had to tell our colleagues in the Ministry, "In America, just saying 'how are you' is kind of like a greeting, it doesn't mean I'm feeling well. I'm not going to immediately start to tell you that I have fever and a headache, so you might need to ask a few more questions." And then they eventually showed up like on day eighteen or nineteen in my observation period and said they wanted to come out to my--they had only been calling up to that point, but they said they wanted to come see me at my apartment, and they wanted to take my temperature. [laughs] I think it's a little late--eighteen days, I think you've missed the boat. But they came out, and it quickly became 01:42:00clear it was much more about the photo opportunity than it was about the temperature-taking, so the nurses and I had a little photo. Yeah. But they were good. They have a lot of tourism, and they have a lot of West Africans who come, so they had to be careful.

Q: I know you've been on outbreaks before, etcetera, but what was it like coming back to the family?

LINDBLADE: Yeah, that was not so easy. I felt like I had--like you're driving along at one hundred miles an hour, and then you quickly jump off the train, and you keep rolling for a while. I was still really amped up and feeling very high energy, and it came to a very abrupt halt with stuff, and going back to my--I'm sure everybody says this, you go back to your day job, and it just doesn't seem as important anymore. And adjusting to being back with the family was not super 01:43:00easy. I know it wasn't easy for them to have me come back, because I just wanted to go, go, go still, and they were--they were very happy to see me come back and very--you know, proud of my time, and I was very proud of them, that they--it was the longest that I'd ever been away from them, and my husband really stepped up to the plate and took care of the kids and made sure that they were still doing all their activities and not feeling too lonely, and they put on a--it was very cute. I had missed a number of holidays, and so they actually did this little play where they reenacted all of the holidays for me that I had missed, even holidays that we don't celebrate, and it was very cute. And then my husband had a Thanksgiving dinner cooked for me the next day, too, because I had missed that. It was very sweet.

Q: How long were you in Thailand, then?

LINDBLADE: I left again in February, so it was almost exactly two months. I was there two months before I redeployed. I was originally supposed to go--I 01:44:00originally went back to Liberia, but it was towards the end of that first wave of cases, so after I had been there a couple of days, they thought they had gotten the last cluster and that there weren't going to be any more cases. Sierra Leone had some needs, and so I flew up to Sierra Leone and ended up spending the rest of my time there.

Q: Tell me about that.

LINDBLADE: Well, Sierra Leone was different, and it was fascinating to be in a different country facing the same problem but with a completely different organizational structure and different mix of international players, and I had a different role. I ended up going into the Western Area, which is Freetown, and being the epi lead for the Freetown area. WHO had a much bigger presence by that time in all countries, but they were a major player in Sierra Leone. Luckily, the WHO had for Freetown somebody I had already worked with in Liberia [Dr. Jeff 01:45:00Gilbert] and had worked with previously--or not worked with but had at least known through conferences in Thailand, so that was nice to have that relationship. That helped a lot and made sure that we worked well with WHO. But they had allocated the sort of sub-areas of Freetown to different organizations, so it was CDC, WHO, MSF, and the African Union who all had clusters of communities. When cases were reported, if we would identify whose area it fell in, it would be that organization's responsibility to accompany the Sierra Leoneans on the case investigation and all the contact monitoring. So we divided our labors that way. I didn't get as much hands-on at that point because there was a need to somewhat stick around what they called the WAERC--the Western Area Ebola Response Center--to help with the overall operations and to be there with 01:46:00WHO when stuff happened with the Ministry [of Health and Sanitation], but I got to go out sometimes with the teams that we had. We had a really interesting group of people who had come again from all over CDC, including one woman who was the first in her family to go to college, didn't even own a passport before she volunteered to go for Ebola in West Africa and Sierra Leone. And she was great. She had this great rapport with all of the field guys, and she and her partner had their cases and contacts and had great relationships with them, saw them every day, and would joke and talk to them, and man, that made such a difference. They were able, then, when people started to feel sick, the people they were monitoring had confidence in them and were willing to follow their advice about going to ETUs and getting tested, so it was good.

Q: Do you remember her name?

LINDBLADE: Jacquelyn [McCullough]. Jackie--yeah, I can give you her name. She 01:47:00would definitely be an interesting person. It was hard for her. I think she got a little emotional at times but really--I think really loved it. I would be very interested to see some analysis at some point about what this experience does for global health at CDC and for the United States, because I think a lot of people got exposed to it [global health] and hopefully a lot of them got really energized and excited by it and are going to start joining our international activities.

So, Freetown was very different. I've worked in mostly rural areas in Africa--only rural areas, really, and I'd never seen the kind of urban slums that are in Freetown, and it was something I had never thought I would see--just really horrendous conditions for people to be living in. A lot of sanitation deficiencies and poor housing standards, and they're right up--Freetown goes 01:48:00right down to the ocean, and it's just garbage everywhere, and pigs snorting through the garbage, and no sanitation. Those were amazing circumstances to find people sick in and to have to go around and have to do these different monitoring activities and case--Sierra Leone was very big into door-to-door stuff. They would do these campaigns where they would go door-to-door and try and talk to everybody in the household and identify actively cases or people who may be sick and then also do contact monitoring as part of it. But it became--pretty quickly after I got there, the Ministry was interested in setting up a quarantine facility because they had a couple of situations already with large numbers of fishermen who had become sick, and they had no place to put them and monitor them well. They had already started putting people in police barracks at this police training school where there was actually also an ETU, 01:49:00and they wanted to make this a formal strategy and to start using it more effectively. I had had this experience in Liberia, and I said, yeah, this is an appropriate thing to do. If you have these quarantines in Freetown that are ineffective because people are either leaving or because their living conditions are so horrendous that you can't keep them there, then I think this is a viable alternative. It took us a while to get complete buy-in. WHO was really resistant at first, and MSF kind of, depending on who you talked to, was hot and cold on the idea, and we weren't sure about the Ministry's ability to manage it. We really wanted the British to set it up and to manage it, but they also weren't on board at first. With the go-ahead of CDC, we kind of did it on our own, like literally procuring with the help of eHealth [Africa], a local NGO, everything that was needed, from sheets to washcloths to basins, and refurbishing these 01:50:00police training schools. Even setting up the little keyboard that had all the keys located for the different places. We did that, and we spent--I stayed an extra week to try and help set that up, and we got it functioning. I heard mixed things about it afterwards, that it ended up sometimes becoming a political tool because Sierra Leone had sort of a punitive [i.e. mandatory] quarantine approach where they forced people to stay in quarantines. They quarantined too large of an area. They had this idea that you had to quarantine around a toilet, so they would quarantine very large areas, and a lot of times the people who really weren't affected would obviously not want to be stuck in these quarantines, and they would start pressuring for the people who were affected to get moved out to this [volunteer quarantine] facility at [the police training school at] Hastings. But those weren't necessarily the high-risk people, and I think there 01:51:00were a lot of people put into this complex who were not really at high risk. I'm not sure in the end how effective it was in stopping transmission. But at least for the endgame, when there were very few cases and you really wanted to make sure that you were monitoring every last contact, I think they were able to use it much more effectively.

Q: What were some of the--like MSF and the other partners' reservations initially about the facility?

LINDBLADE: Sort of a human rights issue, that--I mean, they were also against this sort of punitive [i.e. mandatory] quarantine as well. But they just--I think there were two concerns. One was the human rights aspect, in that you shouldn't be forced--that there's no biological reason that these people have to be put into quarantine. They're not sick, they're not going to be infectious until they start to show symptoms. And you're forcing them to live away from their homes. The other aspect was that people were concerned that transmission would occur within the facility, that you're basically just concentrating this 01:52:00density of cases and you're going to end up causing even more transmission. I guess my response to the first one is that if used properly and voluntarily, which was the way that we recommended it be done, and I--given the conditions that some of the people were living in, I just don't buy the argument. I think that you are putting them in a humane, safe, and well-maintained area where they could get immediate treatment if they became ill. You were actually more likely to save their lives, and you kept them comfortable during the period when they had to be monitored. Yes, in the United States you wouldn't have to move people away from their homes, and it's true that they're not infectious until they become symptomatic, and even then not very infectious for quite a while, but the conditions that the people were living under and the lack of communication, the lack of access--practically speaking, you were much better off moving them away from crowded conditions into a place that was better monitored. Then in terms of 01:53:00transmission occurring inside the facilities, I don't yet think that there were ever any documented cases. Again, now that we know that it's really the death itself that is the most dangerous--not to say that people can't get infected before, they can. But it's just a much lower risk period. The idea that in a quarantine facility where you're being checked twice a day, assuming everything goes right, people are going to get caught early enough that you're not going to get transmission inside a quarantine facility. I don't believe that ever happened.

Q: Can you talk a little bit more about the process of going into the facilities? I'm still a little bit fuzzy on it--the degree to which it's voluntary. Completely voluntary? What does it mean to be voluntary?

LINDBLADE: Well, that's a good question. I'm not sure I can answer that. We set it up as voluntary. We continued to enforce that idea. But in the moment when the Sierra Leoneans go to talk to the family, it's hard to know how voluntary it 01:54:00truly is. And, you know, it's a different context there. Their living situation, their government situation, the Ebola situation. I think you need somebody more grounded in philosophy than me to say whether it was truly voluntary or not. But there weren't guards posted, and people really could have left if they wanted to. It certainly wasn't an internment camp, by any means. There was nobody preventing anybody from walking away.

Q: Sure, whereas in some quarantine facilities it was the case that there were guards posted outside, is that right?

LINDBLADE: Yeah, there were guards posted [at the mandatory quarantines in Sierra Leone]. But again, we know that people left [the mandatory quarantines]. We know that people left regularly. Either they slipped out through back doors or they paid--bribed the guards to get out. But we also know that the guards were mixing with the populations in these quarantines. We had a number of guards become Ebola-positive because they were mixing with the residents, so it was not 01:55:00a very--not necessarily an effective strategy.

Q: What happens then?

LINDBLADE: Well, I mean that was--there were a number of hot spots flaring up in Freetown that were really difficult to get at and several places that were basically under quarantine for months, because that was a situation of concentrating a bunch of people and a bunch of infections in one area, and then they self-sustained for quite a while with transmission going on. So just kept hammering at it.

There was also a disconnect between the contact tracing and the case investigation in Sierra Leone there. We had a really poor oversight on the contact tracing. It was under WHO--well, it was either WHO or UNFPA [United Nations Population Fund], it was always a little bit unclear who had the responsibility for contract tracing. We didn't have good visibility about what 01:56:00was going on. At least in our area, that was like the CDC area, we made sure that our people were going by every day to talk to the contacts [of Ebola cases]. If possible, those that we considered high-risk, where there had been a death in the house, that they [the CDC staff] were going twice a day. The other thing that we told our people was to have a very low threshold for getting somebody tested. I can remember one case, Jackie I think called me that there was a little boy in this family--in fact, we had been to that house the day before, and the family had come out, and we were talking to the family. There had been a death in the house, and there was a little boy. We asked to see the little boy, and so they called him, and he came out of the house, and he had been sleepy. He was rubbing his eyes. He was about four or five years old. And I remember thinking, although I never completed the thought, I remember thinking it's kind of strange that it's eleven in the morning, and he's acting all sleepy. So the next day, we heard that he was complaining of a headache, and I 01:57:00remember talking to--well, I think Jackie called me, and then I talked to the Sierra Leonean who was the surveillance officer for that family and telling them please get him out, take him out, get him tested, because I remembered that he'd been sleepy the day before and the headache, and Ebola doesn't always start with a fever, and even if--we had imperfect measurement of fever anyway, so I was like please take him out and go get him tested. He was a young kid, but his sister was already in an ETU. To take him to that ETU so he could be with his sister. And he was, he was [Ebola] positive. And I felt very sad for him but at the same time happy that we could get him out [and get him treatment]. I think he survived. I don't remember for sure, but I think he survived.

Q: Any other big decisions that you remember having to make in Sierra Leone in Freetown?

LINDBLADE: Well, I guess one thing is that the vice president became quarantined while I was there. One of his security detail died of Ebola, and he probably 01:58:00hadn't been truly in contact with the guy, but he self-quarantined in his house, and it became a political problem. In fact, he became removed as vice president. He wasn't well-liked. I don't remember all the internal politics, but he wasn't well-liked, and so I think his opponents took advantage of him being away in this quarantine and got him ousted. It was--yeah, a tricky situation for a while. He also got very upset with--somebody started--one of the local contact tracers who was maybe a little bit too ambitious knocked on their door to monitor the vice president's wife, and his wife took great offense at the idea that they should be treated like other, normal people, so they got very angry. And then there was an old gentleman who was an old higher-up in the Ministry who had been hired then by WHO as a contact tracer, and so the vice president said 01:59:00only him, only he could come and monitor them every day. It's sort of more funny than anything else.

Q: [laughs] Anyone else who you would like to describe who was important working with in Sierra Leone?

LINDBLADE: James--

Q: James Bangura?

LINDBLADE: Yeah, James. Thank you. James Bangura. He was Ministry--he'd been out at the Lassa fever field station in Kenema before this, and so he had some viral hemorrhagic field experience. He eventually ended up in Freetown, because like Monrovia, Freetown was one of--Port Loko was the other, but Freetown was one of the still--the big hot spots as the epidemic was winding down. He was working with us there, and he was the one who was--who from the Ministry really wanted to get the [volunteer] facility quarantine underway. I really admired him. He had really put himself at risk doing the job that he was doing, and he was a 02:00:00young guy, but--and wasn't from--wasn't in the Ministry of Health in Freetown. His role was a little bit unclear. I mean, his role wasn't unclear, but his position in the government before was unclear. But he threw himself into it, and he was working night and day, and he was somebody that we could call if we needed to get something done, and he would make it happen. He made a personal appeal to me to stay an extra week to do this facility quarantine, and I was like, I can't say no to James. He's such a wonderful person, and the fact that he had--he was risking his life to do all of this work, I thought the least I could do was stay an extra week. Charles Keimbe as well, who was in the Ministry and at the Freetown level, was also really active, but James has a personal charisma that is quite astounding.

Q: So when your Freetown experience winds up, what happens then?

LINDBLADE: I went back to Thailand, back into monitoring with the Ministry, back to my daily phone calls, and didn't--I don't think I thought I was going to go back out again until they called for Guinea. I speak French, but I hadn't spoken it for so long. I had done the post-earthquake response in Haiti in 2010 and never felt very comfortable with my French at that time, but I had been living in Guatemala, and so Spanish had sort of overtaken my brain. So I didn't put myself out as a French speaker when all of this happened. But then in the end, they just, they were so desperate for any even pseudo French speakers to go to Guinea that I went to Guinea. I think I was better at French at that point just because my Spanish wasn't so predominant, so I was able to get by with French. There I had more of a coordinator role. I was coordinating the epidemiology 02:02:00team, and so I worked with, at that point, mostly non-Americans, because we had a lot of Canadians and we had a lot of Congolese working with us. That was a great experience. They all were so enthusiastic and so happy to be working with CDC and really great field people, especially those from Congo, or from the DRC [Democratic Republic of the Congo], who had faced Ebola in their own countries. The same thing I found with the Ugandans I worked with in Liberia, were kind of like, hey, guys, it's no big deal, we deal with this [Ebola outbreaks] all the time. They were very comforting to the locals, that they had been there, done that, and weren't afraid. So it was great to work with them. We worked with several [Congolese epidemiologists] throughout Guinea, and they were very, very effective in the field. WHO was even bigger in Guinea than it had been in the other countries, and it was pretty much just CDC and WHO, and obviously there 02:03:00were many other players involved in different parts of the aspect, but from the epidemiology perspective, it was MSF, CDC, and WHO in Guinea. And Guinea, I think, [my role] is a little bit more management on keeping the epi team running and keeping them coordinated.

I tried to get out to the field as much as possible into the hot spots, like Forecariah, and I spent a little bit of time up in Boke and Kamsar. There was another outbreak that happened up in Boke where it was a family, two girls, their mother had died. The mother's death hadn't been recognized as Ebola, but then both girls became positive, and I got a little--what's the word?--I got it wrong. One of the girls had gotten out before she died and gone to an ETU, and the other one had died but in a health facility, so I actually assumed that, 02:04:00well, that's not a community death, so we're not going to see any more cases out of this girl. But it turned out that even though she died in the hospital she was still touched [by her relatives], and there were many more cases that came out of it as a result, [as well as] her younger brother. So we went to the house, and we sat and talked with the family and tried to explain things and what they needed to do and how to be careful and how to let us know if--you know, let the contact tracers know if they were feeling symptoms. But her younger brother--one of the younger brothers who I was sitting right next to--ended up becoming sick, and I don't know if he survived. I think he did. And then at one point, though, the grandmother became very sick, and they didn't take her in. They ended up driving her around. She eventually died, and so then there was yet a third generation of cases, so that was kind of frustrating.

The response was evolving. We had the addition of the vaccine trial that was 02:05:00going on in Guinea, which gave a lot of hope and in the end turned out to be pretty effective. Coordinating with them was always a little bit of a challenge.

I think what was most interesting about Guinea was the idea of the safe burials. I remember being in a meeting in Conakry, and they were talking about a woman who had died, they had transported the body here, and then they had transported the body there, and she had been manipulated, and the body had been washed and cleaned, and then she had a safe burial. I remember thinking, oh my gosh. Where was the safety in that? Like, how in the world? "Well, we have to call it a safe burial. If the Red Cross buries them, then it's a safe burial." I thought right away, okay, we've been messaging this wrong, and we've been using the wrong 02:06:00indicators. Yes, we need to count the number of burials that the Red Cross does, for sure, but we also need to be determining whether that body was touched before they died or not and labeling that as whether the body had been touched--a very simple indicator. So we started talking about that a bit more. Then we ended up from some of the data that the teams previous to me--and I think maybe Pierre Rollin was the one who set this up--had done a really good job of systematically collecting very detailed transmission chain diagrams that had the information of whether the person was put into a CTE, they call them there, Centre de traitement Ebola, ETUs, but the acronym is CTE--when they had gone in, what their outcome was. From these transmission chains we were able to abstract that data. I mean, I'm sure it was in a VHF [viral hemorrhagic fevers] database somewhere, but the idea about these transmission diagrams is it's 02:07:00population-based, and the epidemiologists were out there tracing all the cases that were occurring in the village and all of their contacts, and so you have a much better idea of whether you've captured all the cases. Now, yeah, we may have missed some, but it's much better than I think the data that you just pull out randomly--or you pull out from a database and aren't necessarily linked, and you're not sure that you've got the complete picture. So using that data that had recorded information on whether the Red Cross had buried the bodies or not, a so-called safe burial, we were able to look at the number of secondary cases that came from people who had been buried safely and those who had not been buried safely, and we didn't see a significant difference, which again is what we knew anecdotally, that these bodies were being manipulated and washed and touched long before the safe burial team arrived. It was just a misnomer to call them safe burials. But I think that was kind of reinforcing what everyone knew, and there were a lot of debates at the time of how much effort should be put 02:08:00into the safe burial. We also realized we were messaging it wrong, and we should have been talking about safe mourning, or even just a very simple message of: do not touch the body after death. Instead the message was: give them a safe burial. It was not targeting the right kind of behavior.

The other thing we looked at from that data and were able to combine with Liberia data was again about this idea of isolation. It seems so obvious to say, but this idea that if you can get the cases out of the community before they die, you can essentially stop transmission. The number of secondary cases, the average goes down well below one, and so that means that transmission will not be sustainable. But we were able to show that, to show those data to the authorities and to say that where you're getting [secondary] cases are [from] the community deaths. So we're not saying stop monitoring all the other contacts. What we're saying is that when you get somebody who dies in their home in the community, you need to double down on the contacts of those cases. You 02:09:00need to put your best epidemiologists and best contact tracers on them, you need to be following up twice a day, you need to have a lower threshold for getting them tested, and you need to move them very quickly to an ETU. That message, I could see, was starting to trickle down. We were starting to talk about high-risk contacts, starting to stratify the contact list, starting to monitor those high-risk contacts and when they moved out of their sort of window of most likely becoming ill, and I think it just helped to focus the attention where it needed to go and give them the kind of priority that they needed to have.

Q: So you think that was pretty effective, the idea--the messaging we really need to double down on any kind of community transmission?

LINDBLADE: You know, it's always hard to trace these things and to credit some of these findings, but I think that is one where I feel comfortable to say that, yeah, I think that our comments on this and our continued reference to that seem 02:10:00to be taking hold. I mean, during that time, Bruce Aylward came out from WHO, and he wasn't necessarily supporting this idea, but I heard him also starting to talk about high-risk contacts, so I think that idea anyway that there were higher risk contacts was something that definitely became institutionalized.

Q: And how about when it comes to handling the body after death? Were there changes made?

LINDBLADE: That--I don't know about that. I was leaving around the time that that--I didn't really get those data until--or get it all ready to be analyzed until I was pretty much leaving, or right after. So we made a presentation to the Ministry on my second to last day there where we talked about this stuff, but I didn't stick around long enough to find out if they changed their practices around the safe burials. I mean, it just--again, if you get cases to 02:11:00an ETU before they die, then it's not a question, because they will all be safely buried in the ETU, because no one will be touching the body. So the message is still monitor the high-risk contacts more intensely and move people as soon as they become symptomatic to an ETU, and then actually it [safe burial in the community] doesn't really matter. The safe burial issue is gone if you can do that [treat Ebola patients in an ETU], because pretty much by definition, all the burials in an ETU are safe burials, are truly safe burials.

Q: Are there any particular FETP grads who stand out to you when you look back?

LINDBLADE: Several, but I think I've forgotten all their names. Yeah, there were several, the guys who were down in Forecariah. Yeah, I don't remember their names now.

Q: That's okay. Anything about them?

LINDBLADE: We would go out to eat. They had this one favorite restaurant where 02:12:00they would eat every night, and I just remember hanging out with them in the evenings and chatting with them about what was going on with the response. What FETP had done for them was really changed their mindset from a clinician's perspective to a public health perspective. I just realized that that made a huge difference, that they understood what needed to be done in a way that a general physician from that area wouldn't have known, and they were just very oriented towards public health and towards making decisions that were going to have the greatest benefit for the largest number of people. So I remember being very appreciative then of the work of FETP. They knew the population, and they understood the public health significance, they understood about disease transmission in the community, and they were going out every day to remote 02:13:00communities, really bad roads, and talking to people and working with them to understand as best they could what was going on and what they needed to do to protect their communities.

Q: Okay, well, we're about to wind down here, but one thing I really want to ask you before we go, given your expertise in the interrelation between environment and infectious disease, was that something you were able to focus on ever in the context of Ebola in West Africa?

LINDBLADE: [laughs] No, no, I mean, we were all about stopping transmission, so there was--yeah, I'm generally interested in and a bit attuned to the ideas of human contact more with the environment, and I followed for many years all of the work that's been done on the different USAID grants that have been trying to predict the next sort of hot spots in disease transmission from animals to 02:14:00humans and how that's happening more and more as we deforest and degrade the environment in many places. There's just more human-animal contact in ways that we didn't have it before. So I was aware of it, but it just didn't come into play.

Q: How about afterwards, have you been able to do any looking at it?

LINDBLADE: No, not me. It's one of these things that's going to continue to happen. We continue to change the ways that we interact with the environment, and we continue to change the environment, so we know that there's going to be new transmission patterns and new relationships between humans and the environment that's going to lead to disease, so I don't expect that--I think we'll have jobs [in public health] for a really long time because that's going to continue happening in ways that we can't even begin to fathom. Trying to 02:15:00predict it, I think, is kind of--I know a lot of people are spending a lot of money on it, but my personal opinion is we're not going to be able to predict it because there's just so many factors. Who would have thought that H1N1, for example, would have come out of Mexico? Nobody was looking for the next pandemic to arrive from Mesoamerica. So to think that we're going to be able to predict where the next outbreak is going to happen is, I think--aside from the fact that it's likely to happen in countries that have poor health infrastructure, I think it's just--I think we just have to build up the health infrastructure everywhere as best we can and then respond once we need to.

Q: Well, I know you have about ten minutes to get to your next thing, but I want to ask, is there anything else that you'd like to share about your Ebola experiences to make sure we have on the record?

LINDBLADE: I came away with just an overwhelming feeling of pride for working for CDC. The people that we had come out and who were selflessly giving away 02:16:00their family time, missing holidays, putting themselves at risk of road accidents--I wouldn't--you know, we weren't really at risk of Ebola, but we were at risk of many other things--and being professional about it and being low-key about it, and we're not the agency that puts our stickers all over things, we're the agency that tries to get the job done and tries to do it the smartest, most efficient way possible and always using the best evidence that we have. I almost didn't get to [work for] CDC, and I am just so happy that I did.

Q: Thank you so much for everything, for your time and your stories. It's been brilliant listening to you.

LINDBLADE: Thank you for the opportunity, I really appreciate it.

END