Dr. Margherita Ghiselli

Dr. Margherita Ghiselli

Q: This is Sam Robson. It is Thursday, December 1st, 2016, and I'm here with Dr. Margherita Ghiselli. Thank you for coming back here, Margherita. This is our second interview as part of our CDC [United States Centers for Disease Control and Prevention] Ebola Response Oral History project here at CDC Atlanta. This time we thought we'd focus in on gender. Before I hit record, I was just asking Margherita about her general experiences before Ebola, even, with what WHO's [World Health Organization] gendered culture was like, what she noticed there.

GHISELLI: My experience has been with WHO AFRO [African Regional Office]. In my posting in Gabon, I noticed immediately that I was one of the few women who were not on the administrative staff, meaning on the technical side [of polio 00:01:00eradication]. There was only one person, one other woman, when I arrived [in March 2014]. She was one of the two data managers in Gabon. She had been a good friend the first time I had been in Gabon during the STOP [Stop Transmission of Polio] project, and we reconnected when I was posted there for the two years. She left Gabon to go to Brazzaville, to the AFRO regional office in Brazzaville, so for a short period of time, I was the only woman there on the technical staff. Very soon after though, another person, another woman arrived. She is originally from Niger, but was coming from the provincial office in DRC [Democratic Republic of Congo], from Orientale Province, and she was coming to the IST Center, the Intercountry Support Team for central Africa, so in Gabon with us. She also was working on polio eradication. For the two years that I was 00:02:00there, we were the two women on the technical staff for our team. We both had similar roles for focusing on polio eradication, supporting the countries, and we both were traveling quite a bit. She went to Cameroon for an extended period of time as team lead when there was the polio outbreak there in 2014, so she was supporting from there, and she, obviously, participated in a number of other missions as well. We were together in Burundi when we went for that training session for Central Africa for the polio expert committees for the Central African countries. But the thing that I noticed immediately was that we were definitely the minority, and that this was something that was well known within 00:03:00AFRO in general, that there weren't that many women providing technical support. All of us had either medical degrees or--anyway, advanced degrees at the technical level.

For me personally, that was never an issue, being a woman. Seniority had much more to do with that. I was the youngest one in the team, and in reality, it played very well within my team because my supervisor and my colleagues were [supportive] of me in the sense that they would take the time to explain the functioning of the WHO, the different relationships with the ministries of health, the political aspects, the technical aspects. The questions that I would ask would always be answered very clearly, and people would take the time to discuss this with me. On the other hand, there might have been times when I was not put in leadership roles because I was the youngest one in the group, but it 00:04:00was always very clear to me that it was a matter of age, not of gender nor race. So in that sense, the gender imbalance within WHO AFRO was something that I noticed but I never felt that it was holding me back personally, but there was very clearly a gender imbalance, and this is well known and has been discussed within AFRO for quite some time. Now with the new regional director being a woman, maybe things will change, but we'll see.

Q: I can look this up if you can't recall immediately--do you know her name?

GhiselliI: Dr. [Matshidiso R.N.] Moeti. Moeti is her last name. I believe she's from Zimbabwe.

Q: Did you ever have a chance to get to know her a little bit?

GHISELLI: I did meet her in Sierra Leone. She came to visit the hospital in Port 00:05:00Loko and I was invited to [participate in her field visit] as Kambia field coordinator. I went, and the field coordinator for Port Loko, the WHO field coordinator, Boris Pavlin and I, had a chance to do presentations for our own districts and show what kind of data we were able to collect at this point, what kind of mapping we were able to do, and therefore what kind of contact tracing and case finding we were able to do. It was clear that she was being taken on the tour of this hospital and she had quite an entourage, so it was kind of difficult to move in the small corridors of the hospital. But Boris and I had time to talk with her afterwards. But that was my only encounter with her.

Q: Once Ebola hits, once you get to Kambia, you talked in the previous interview about some--I think it was mostly smaller things that you noticed, about the 00:06:00district medical officer and district coordinator and how they treated you, and Helen Richards, who was--Helen was, again--

GHISELLI: Helen is a colleague of ours from DfID, the British Department for International [Development], and she had been assigned to Kambia to support UK [United Kingdom] operations within the district, in addition to the British military and other representatives of the UK government.

Q: For instance, you mentioned that at the end of your service, the DMO [district medical officer] and DC [district coordinator] were more openly thankful of your male colleagues than of you. Were there other instances like that when you look back that you can recall?

GHISELLI: I think that as you say, they were small things. There was never some 00:07:00very clear-cut difference between myself and my male colleagues, and I want to emphasize that this was more at the level of the DMO and DC. With the other Sierra Leonean colleagues, there were never any issues. We were part of the team, we worked very well together. Within the DERC [District Ebola Response Center], there were really no problems. With DMO and DC, it was just an impression of not communicating very well or having a preference of--especially for the DC--to communicate through Mike McKee, [a DfID representative], and just preferring that venue of communications rather than what I had hoped to create, which was a very direct and open [channel of communication], especially with the DMO on all matters related to the response. Now, it could have been that the DMO was busy with other things as well. Ebola was [only] one of the issues that 00:08:00Kambia had. I believe the biggest one, but certainly not the only one. Maybe there were differences in styles, and he didn't feel comfortable. Maybe it had nothing to do with gender, but [this difference in interaction] was something that I noticed and Helen noticed as well. Mike McKee made it his special mission to have a very direct relationship with the DC, serving as his advisor, presenting our points of view. So while the DC was a little bit more open towards myself and Helen, Mike McKee put a lot of effort into that relationship, so it made more sense that the conversation would go through him. That is not to say that we would not hear information from any other source except Mike McKee. A lot of information was shared within the DERC. It's just that when one-on-one conversations happened or small group conversations happened, they tended to be 00:09:00with Mike more than the rest of us.

Q: I remember that you had talked about Mike kind of serving as a bridge of communication in our first interview, so that gives me a picture of how that looked. Do you think that that indirect style of communication--it might be hard to speculate, but what kind of effect do you think it might have had on the response, on your work?

GHISELLI: I don't think much. Otherwise, I would have tried to address it much more strongly or at least found some other way that would have been more acceptable if gender [relations] had been an issue, a true impediment to activities. I don't think it was. It was just a general sense that with the UK military, men in uniform, that was just an easier way of communication. Mike 00:10:00McKee was not in uniform. He was part of the British government, but he was not military. But I believe he had a military background, so he knew how to present things. And of course, having Henry Dowlen, Major Henry, there from the Royal Marines, who was in uniform every day--I think that just made it a little bit more comfortable in terms of relationships. I've heard the same thing from Port Loko as well, that the men in uniform had a better rapport just because Sierra Leone, lots of military history, a civil war. The military in its uniforms, it's very clear with whom you're speaking. So it was more impressions and little things, but I don't think any of it had a real impact on the way we worked on the response.

Q: Just comparatively, did you find similar things going on, a similar dynamic in Guinea?

GHISELLI: Guinea was a little bit less, I will say, maybe because there were so far fewer foreigners. It was much, much more Guineans, and some FETP graduates from DRC. FETP is the Field Epidemiology Training Program that CDC establishes in the different countries. FETP graduates from DRC had come to Guinea as part of the CDC rotation, but it was still an African response. Of course, there were also members of the African Union who were there, but still it was an African response. In terms of Westerners, there were so few of us in Guinea that I think that gender didn't really matter. It was more a matter of being part of this Western group. But then again, I was WHO AFRO, so that put me kind of in a hybrid position, which was very good for me because while being a Westerner, I 00:12:00still was part of the local regional office and not an attache. I was kind of like staff. That already gives me some clout to begin with. I'm a WHO international staffer. I got a lot of street cred [credibility] because I live in Gabon, [I'm] not just flying in, I was considered part of the local response.

Q: Do you recall any reactions that people had when they learned that you were living in Gabon?

GHISELLI: It was surprise. It was like, you live in Gabon? Yes. Yes, I do. I have a house. I live there. That's where I'm going back. People were surprised, but I think also quite pleased. It gives me some credibility that I'm not just someone who's coming in for a couple of weeks and then goes home to--so I was coming from Africa to support another African country and then going back to Gabon. It indicated a long-term commitment I think more than anything else, and 00:13:00again, being a WHO staffer also makes things easier because I'm part of the organization, not a consultant, I'm actually staff. If there's any administrative issue, I can help out.

One funny thing that happened on my second day in Guinea: the first day I had my orientation, and the second day I was told, you do the orientation for this new group. You're staff, you know these things. I was like, okay, this is my second day in-country ever, but sure. These were all consultants coming from GOARN [Global Outbreak Alert and Response Network], so helping everyone obtain credit for their cell phones or making sure that everyone had--well, everyone had a hotel [reservation], but making sure that everyone knew where their drivers were and how to be picked up and the timings and what kind of information do we have 00:14:00on the country. Obviously, I can't tell you where you're going in the country, but an overview of the situation, things like that.

Q: It's bringing to light that when we focus on one specific kind of axis of differentiation, of gender, there's a lot of other things you have brought up like foreign versus local and seniority that also differentiates people that kind of crosscuts all of these things. So when you came back to Guinea with CDC and were no longer WHO staff, did you notice a difference?

GHISELLI: The WHO office didn't seem to think so. They were happy to see me and they were like, well, just come over any time. Obviously, I wasn't part of their internal deliberations, but then again, [within] central level, I had never [worked]. But the deputy WR [WHO representative], Dr. [Mamoudou Harouna] 00:15:00Djingarey, and Boubacar Diallo, who was the person responsible for the WHO response to Ebola in Guinea, they were happy to see me and they had no issues in just pulling me in in whatever meeting the CDC response lead would be in. I was acting as deputy at the time, so there was no breach of protocol in drawing me in, but it certainly made conversations very easy to have someone like me at the table whom they worked with before internally, never caused any problems really, and now is just here to help out again. Access, I already had because I was deputy response lead. But a level of trust that I don't know other people could've obtained in such a short amount of time, and I was there present in all meetings. Everyone knew who I was, so it was easy to jump in. But because of 00:16:00that trust, gender at that point really didn't matter at all because as an individual, I was already a known entity.

Q: In your work since Ebola, when you have gone to areas that you hadn't really spent a whole lot of time in before and didn't have that ongoing rapport with people, have you noticed more of a contrast of people buying in and trusting you?

GHISELLI: Yes, actually. I spent two months in Angola working on the yellow fever response, and Angola is--for WHO African Regional Office, Angola is part of Central Africa, so they would fall under my IST Central. There were already a number of colleagues I knew in Angola, a number of them came from Gabon to support the response. The EPI, the Expanded Program on Immunization point person 00:17:00for WHO for Angola, had worked with us in Gabon, so he knew me quite well. Again, he was happy to see me. For me, there's obviously a tendency of working closely with WHO. It's what I know best. For me, at least at the country office, there's no difficulties in trying to understand also the sometimes difficult positions WHO is in with the ministry of health and trying to be sensitive to that. Again, in Angola, I didn't see much of an issue at all and at that point I was also coming as CDC team lead. So again, access wasn't the issue either. No, in Angola, it really wasn't an issue at all.

Q: I want to go back to your time in Kambia. You mentioned something in our first interview that I didn't follow up on, but I didn't completely understand 00:18:00what you had meant, and that was when you were talking about in Sierra Leone how women's roles were circumscribed to not even including like menial tasks. Which women were you talking about?

GHISELLI: I was thinking mostly of the women--well, or the lack thereof, of women who came to the DERC to do clean-ups or prepare meals or do any kind of the administrative office clean-up, office management tasks. I was just surprised because in every other country I've been to, women are usually the ones you see cleaning the floor, preparing the meal, and here it was only men, even for these tasks which I had always associated with women. I was just surprised from that and my personal thought, well, maybe because there's money 00:19:00involved, men take up these jobs. Of course, the economy in Kambia was never flourishing, so probably the amount of jobs paid in cash wasn't that many to begin with. Then when we went into the villages, obviously, it was mostly men who participated. There were some women, but they were always standing in the back. In Sierra Leone, the Sierra Leoneans who participated in the response, there was no difference between men and women. Everyone carried their weight. But then again, they had all been selected in Freetown to come and support us and then assigned to the districts, so they were taken from a pool of university students who had applied for the job, so already coming from a very different background. Obviously, you would have much higher socioeconomic level, you would have people who maybe traveled abroad, so obviously, once they came to Kambia from a pool in Freetown, there was no difference between men and women. It was 00:20:00something just that I observed from people living in the district.

Q: This is a really broad question, and I apologize. But since you've been with CDC, what have you noticed about cultures of gender here?

GHISELLI: Here at CDC.

Q: Here at CDC.

GHISELLI: Interesting. In Atlanta, I don't notice any difference, to be honest. When we're abroad, especially--my biggest example would be Angola where I spent the two months. Of course, there's all the security restrictions of not walking alone at night, not walking around by yourself, paying attention to where you go. Sometimes--I'm trying to see if I can phrase this correctly--I don't know, 00:21:00because being abroad is such a different experience for so many people that I don't know if I want to generalize. It's an unusual situation for both men and women being abroad, for most people who deploy, and Africa is not easy, so maybe their behaviors would be different than in Atlanta. Obviously, more hesitancy to take initiative or to move around or to break with protocol or with CDC's very clear guidelines of what is acceptable and what is not when dealing with the ministry of health. Things like that. I don't know if it has anything to do with gender here at CDC. It's more a matter of when you're deployed abroad, how 00:22:00comfortable you are interacting with a different culture in Africa, which a lot of people see as a dangerous place. But in Guinea, oh, at that point in Guinea, so many CDCers had been that things were much more relaxed. Again, maybe it would've been interesting to see how many people at the height of the response would have agreed to go out into the provinces and whether that was divided by gender, and was there any difference by gender. But at that point, we were pretty much all of us in Conakry anyway, staying at one of the three or four hotels. So there really wasn't any difference there, and here at CDC in Atlanta, there's no issues. I will say though, very interestingly, that this new generation of rapid responders--at least at CDC--is very heavily female, which 00:23:00is not the case if you look at the previous generation. Maybe seven or eight years older than us, they're all men, and now we're all women, and it's something that I've noticed in WHO as well, a preponderance of women. That might be the only gender imbalance I see in Atlanta.

Q: I think that really does it for my questions. Were there any other reflections that you have on this subject, or anything you didn't talk about in the first interview?

GHISELLI: Well, in terms of gender imbalance, I would just want to mention how casually this issue has been dealt with during the response. I think I mentioned in an email of mine how for the survivors, all the benefits--of course, benefits 00:24:00are for all men, women and children who are certified to be survivors, and that's fine. It's just that the focus on semen testing, which makes perfect sense from a scientific point of view, biases all the attention on the adult men. One of my concerns: aren't we inadvertently not paying the same attention in recording the movements and whereabouts and existence even of the women and children? It was interesting to see how this focus on adult men was almost eclipsing everything else, because obviously they were the ones who are still the carriers. From a scientific point of view, it makes perfect sense, but aren't we forgetting also to register the women and children who sometimes are the most vulnerable in these situations, and who are not as autonomous as they 00:25:00are? Maybe they need these benefits even more.

Q: That is such an interesting question.

GHISELLI: It will be interesting to see how things went. The other point that I wanted to make is for my colleagues in Guinea, who during the cerclage at the very beginning were asked by their male colleagues to do their laundry and cook their food. They quickly said no. Again, these are all physicians, graduates from the medical university of Conakry, so very high skilled, highly educated people. I just found interesting the assumption that they would do this for their male colleagues. They said no, and we very much reinforced that, but they had maybe an easier time because they did the cooking and washing for themselves, while the guys had to--one of them at the time had to go back to 00:26:00Forecariah each evening to buy dinner for everyone else, and then had to find some relative or someone in Forecariah to do their washing because they didn't want to do it in the villages. The women just had better survival skills, and for the men it was more difficult, but for the women I think it was much more difficult to have to be in--just be in these villages. They put a partition in the tent to separate men and women, but at the beginning it's not possible. The men were always, I'm sure, very sensitive about this, and the women dress in the tent by themselves. I've never heard of any incidents, and I never saw any symptom of difficulties between men and women. It was just something that the women would say to us, sometimes it's difficult. But then again, the whole 00:27:00situation was so difficult for those doing the cerclage, this lack of privacy was an added issue. But the partition did help a lot. It was just, again, cerclage requires a lot of resources, and at the beginning there was a different tent for women, but the military took that. The distinction between men and women had been thought about when organizing their cerclages, it's just at least not in Benty, it was not possible to implement it. Alternative solutions were found, but it just added to the difficulties, and that request to cook and clean for them--[laughter] No, we are not doing that because it's already hard work and we don't need additional--because there's like fifteen of them all total, and the women were five.

Q: I like the way that you very rightly put it that the women just had better 00:28:00survival skills.

GHISELLI: In terms of washing and cleaning, yes, and obviously, they wouldn't want to eat food in the village. The villages are infected with Ebola. So the fact that someone always had to go and find dinner in Forecariah and then the women would cook their part and the men would make due. But yeah, no, it's just a matter of how you can live independently and in such difficult circumstances. If I had done cerclage, I would've been completely dependent on them as well because I don't know how to do the washing and cleaning in these conditions. But still, the women were better equipped to do this, and it was just not something that had been thought through. It's like, how are you going to do your washing? 00:29:00Fortunately, Forecariah is two and a half hours away--bumpy roads, but you can do it. If it had been farther away, it would've been more difficult.

Q: Thank you so much for coming back and doing this second session.

GHISELLI: Of course. Do you think you'll have other women talk about their experience?

Q: I do, and I think I should ask men as well. I should just ask everybody.

GHISELLI: Yeah, because even the CDC colleagues who came to Kambia and--who came to Forecariah? I think they were all men, but a couple of women came to Kambia. It would be interesting to get their perspectives as well, how it is to be a woman in these rural areas. Again, I did not see any clear disregard of me. It was little things, and it did not impact the response, but it would be interesting to see if at any point it did impact the response. Also, in terms of 00:30:00the people affected by Ebola, whether being a woman had any impact on whether you got treatment.

Q: Right, yeah. One thing I didn't ask about but I think you started to touch on in our first interview was how the social dynamics you would think would dispose women toward a greater risk of transmitting Ebola, of contracting Ebola, because they're the caretakers, they're at home, they're in the environment that's rife with transmission. And then you look at the numbers, and I looked at this--my only source for this was this New England Journal of Medicine letter to the 00:31:00editor that said that--I think the statistics or something in West Africa, like women were fifty-one percent of cases and men were like forty-nine. So it's a difference, but it's not as huge as you might imagine, and it to some degree follows just the differences in population. But I think that still has to have some sort of effect, the different places you get--there must still be some differences between where and in what situations men and women were infected. I think the same letter said that--sorry, I'm talking a lot. Said that men were more likely to stay in the community longer than women, and so that would mean that they spent more time in the community when they were more highly--

GHISELLI: Infectious. Yeah, so maybe in the end everything balanced itself out. It was just something that we noticed: if women are the caretaker, it would naturally follow that they're more likely to be exposed, and what are the 00:32:00consequences? Would a family take the money and the time to take them to an [ETC, Ebola treatment center], versus trying to cure them at home? It was all dynamics that we were never able to explore. We were so focused on contact tracing and case finding, but it might be interesting to understand the dynamics of that.

One last thing that I wanted to mention in terms of women in the community. When we were doing contact tracing and trying to find these contacts, we always--well, not always, but frequently we noticed that the women would turn to their brothers for help. Even when their husband was living with them and their parents or uncles were in the community, they often would turn to their brothers, and we always found that to be interesting, as that one male relative whom you can trust enough to take you on his motorcycle and cross a district with you. We noticed that relationships with brothers was always very important, 00:33:00even when other relatives were within reach. We always thought that was interesting, but I don't know how frequently that happened, but we found that quite a bit, especially in Benty sub-prefecture.

Q: I wonder to what degree men controlled the migration of women across regions.

GHISELLI: Well, in Benty, when we reconstructed the transmission chain, we saw very clearly how the man took his wives and his children, started walking, and leaving them at the houses of the women's relatives all along the way. Then for these last ten cases in Nzerekore, in Guinea in April, once again, it was a woman asking her brother to take her and her two children, and I think these were the cases that ended up in Liberia. So a man might take his wives, but a 00:34:00woman might ask her brother to take her somewhere. These were the two main trends that we saw, men taking their wives and women asking their brothers to help them out. That was something that I found quite interesting.

Q: Thank you so much, Margherita. Really appreciate it.

GHISELLI: Of course. Any time.

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