Dr. Margherita Ghiselli

Dr. Margherita E. Ghiselli

Q: Hello, this is Sam Robson, here today with Margherita Ghiselli. Today's date is September 2nd, 2016. We're here in the Atlanta headquarters of CDC [Centers for Disease Control and Prevention], their Roybal Campus audio recording studio. I'm lucky to have Margherita today here talking about her experiences with the Ebola response as part of our CDC Ebola Response Oral History Project. So, Margherita, thank you so much for being here.

GHISELLI: Thank you.

Q: Could you start out, if you could pronounce for me your full name and tell me your current position with CDC.

GHISELLI: It's Margherita Emilia Ghiselli, and I am an emergency public health epidemiologist for the Emergency Response and Recovery Branch, based here at CDC headquarters.

Q: Gotcha. Can you tell me briefly what your role was in the response? Like title and where you were and who you worked for?

GHISELLI: I was working for WHO, World Health Organization, at the time. I was [a CDC secondee] to the AFRO [African Regional Office] region of WHO, 00:01:00specifically the Sub-Regional Office for Central Africa, based in Libreville, Gabon. I was deployed, I was not a volunteer. WHO staffers for AFRO were not volunteers, we were deployed. I was deployed first to Kambia District in Sierra Leone, between January and March 2015. Then deployed again to Forecariah Prefecture in Guinea, June through August 2015. Then the last time I was back at CDC, so I was deployed as a CDC staffer. This was April 2016, to Conakry, Guinea.

Q: Thank you for that background. So, backing up for just a bit, can you tell me when and where you were born?

GHISELLI: Washington, DC, 1981.

Q: Gotcha. Did you grow up in Washington, DC?

GHISELLI: No. My parents were postdocs and fellows at NIH, National Institutes 00:02:00of Health. We were there for the duration for their fellowships. When I was eight months old, we moved to Houston, [Texas]. That's where my two sisters were born. We stayed there until I was about five and a half. My parents are Italian. So after that, we moved back to Italy. My dad changed jobs, so we moved back to my mom's hometown, where all my grandparents and aunts and uncles were. I started first grade there in the Italian public school system. I stayed there until the end of high school, when I applied to a college in the US simply because I had a blue passport. I had never used it. I wanted to see if I could get into a college, and I did. University of Pennsylvania. My dad was back in the US at the time, working for a grant at Jefferson Hospital University in Philadelphia. So I

basically joined him in Philadelphia. Then my sisters wanted to do college as well in the US. So they came, and at that point my mom came back as well. My

nuclear family is now living in the US, between Philadelphia and New York, and I'm here in Atlanta.

Q: What's the hometown in Italy?

GHISELLI: It's about half an hour north of Milan. It's called Busto Arsizio.

Q: Gotcha. What's it like?

GHISELLI: Very industrial. It's probably one of the least nice parts of Italy. But it's in between Milan and the Alpine lakes. Within forty minutes we are one place or the other. So the surroundings are quite nice. The city itself is very industrial.

Q: Is everyone you know okay after the earthquakes that happened?

GHISELLI: Oh, yes. We were in the north. It's not a seismic area at all. We are all fine. Of course, we've been following the news and providing relief as we can from here. But my family is fine.

Q: Okay. This was recorded just after earthquakes that happened in Amatrice. I think I'm pronouncing that near-correct, maybe.

GHISELLI: Indeed.

Q: Okay, great. Near correct! Can you tell me a little more specifically what 00:04:00your parents did, too?

GHISELLI: Sure. Both my parents have their PhD in pharmacology from the University of Milan. My dad was offered a fellowship after graduation at the National Institutes of Health as a molecular biologist. My mom came as a postdoc in the same field. When we moved back to Italy, my mother with three small children decided to leave that career and started teaching chemistry in high school, which she did for about fifteen years. Now in Philadelphia she teaches Italian language and culture in a non-profit organization in Philadelphia.

Q: Wow, that's really cool. So what was the University of Pennsylvania like?

GHISELLI: It was a very, very--well, I had no idea what US college would be like. I came with very much of a blank slate. But college--the academic piece was not particularly difficult, just because--well, high school in Italy, it's a 00:05:00little bit more demanding. At least the public school system is a little bit more demanding. We had long hours at school and then long hours of homework. So the simple fact of sitting down and hitting the books wasn't--that wasn't the challenge. It was more--well, the English. At that point I had never really studied English before. I had spoken it when I was young. That's how I got my accent, and I kept it. But I had never really sat down and studied grammar or the literature or anything of the sort. So, it was to get familiar with English, getting comfortable in English. And then also just understanding how the system, the structure, works. The fact of changing classmates with every different course, that's definitely not the case in Italy. You stay together in high school--well, throughout elementary school through high school, you stay together in one class and the professors come and go, depending on a set 00:06:00curriculum. You don't get to choose classes. So here, in Pennsylvania, I got to choose the classes. I probably was a little bit conservative to begin with. I wanted to study a different language, so I picked Spanish. In retrospect, I probably could have picked Mandarin or Arabic or something like that. I had not fully understood, at the beginning, what a wide range of courses and interests one could pursue in a US college.

By the end of my fourth year, I was pretty well settled. I was writing for The Daily Pennsylvanian, which is the student newspaper. So my English had gotten to a point where I was comfortable writing and publishing in that language. I studied Spanish for a little bit, then forgot it all. Also, I had the opportunity to major in anthropology and in communications. So it was two different majors. For communications, I was mostly focused on health 00:07:00communication. So how people understand the health information that they receive from either the media or any other sources of information. I was working for a professor there as a grad--not a graduate student--an undergraduate, a research assistant, helping out with his projects. It was a very, very good learning experience. About twenty, thirty hours--twenty hours a week, plus the newspaper, so that was a full schedule for me. But it worked out really well.

Q: I don't know if University of Pennsylvania students have like a senior thesis when they graduate, or anything like--

GHISELLI: It's not mandatory, but for anthropology, if you want to graduate with honors, you have to do a small thesis. And I did one. I believe it was something about code switching. Meaning, when do people who are bilingual switch from one language to another? My sample size was very small. It was not very well done in 00:08:00retrospect. But it got me the honors that I wanted. But at that point I was very interested in--just from my own experience--as to why people switch from one language to another. Because I was seeing my sisters and myself--when do we speak in English and when do we speak in Italian? At home we always speak Italian. But more and more, English words were coming into the conversation. I was interested in seeing if there was a specific pattern or not. Also, because I had a friend in college who was also Italian American, same as me. And he had a completely different way of inserting English words into Italian sentences. So I thought that would be quite interesting to study.

Q: No, it absolutely is, wow. And then was there a more specific area of health communications that you were interested in?

GHISELLI: Not at the time. I honestly can't remember what the--oh no, yes. It was about tobacco smoking. Tobacco and adolescents. Seeing how adolescents 00:09:00receive information about tobacco, and what do they make of it? There were a few studies that were ongoing at the time. One of them was looking at PSAs, the public service announcements, and seeing which one was the most effective. Turns out, I can't remember specifically, but I don't think many of them were widely successful.

Q: Oh no!

GHISELLI: But this was about fifteen years ago, so things must have changed.

Q: Gotcha, yeah. Absolutely.

GHISELLI: Twelve years ago. [laughter]

Q: So what happens after college?

GHISELLI: After college I applied for graduate school. I always knew I wanted to go to graduate school. And the professor for whom I was working suggested health communications. So an MPH, a master's in public health. I applied to a bunch of places and got accepted at the University of Minnesota, specifically for community health education, for that track of the master's. So I moved to 00:10:00Minnesota, never having been there before. Very cold. [laughter] Far more--it's difficult to describe the first time, how cold it can be. It was also a little bit of a cultural shock for me, being used to Europe and then the East Coast, and then the heartland. It was quite an adjustment. But at the end of my first year, I switched to the epidemiology track, just because I was taking already the biostatistics courses and thought I wanted something more quantitative and rigorous in terms of a study track. So I switched, and obviously, having already done the requirements, was accepted. It was pretty easy. Immediately afterwards, at the end of that, I applied to the PhD program also at Minnesota. And thus 00:11:00just continued.

Q: Did you have a final project, like a thesis? A master's thesis?

GHISELLI: Yes. Which I cannot remember, for the life of me.

Q: That's okay.

GHISELLI: I cannot remember. But I remember that I defended it the day after I returned from Vietnam. So it must not have been particularly difficult. With that kind of jetlag, I defended it quite well. So, I cannot remember what it was. It must not have been that--

Q: Or maybe you did an amazing job in trying circumstances. Why were you in Vietnam?

GHISELLI: It's actually quite interesting. That was my very first experience abroad as a humanitarian. Or at least to do anything in the public health humanitarian vein. My aunt in Italy works for this nonprofit that works with international adoptions, and one of the countries where they work is Vietnam. I had told her that I have nothing to do this summer, and she said, "Do you want 00:12:00to go?" Absolutely. So I went for a month. I was interviewing different NGOs [non-governmental organizations] in Hanoi with the help of another assistant in the office, just to see what kind of projects they wanted to propose. And then travelling to a couple of orphanages outside of Hanoi, just to see how the funds that had been sent over had been implemented. I remember one time going to--one of the orphanages is three or four hours outside of the city, and my aunt told me, "We can't understand whether or not they have built an additional floor to the building." Well, that seems pretty straightforward. And then I finally get there, and I see that they've created an additional roof with some pillars. It's not quite an additional floor, but it's a space that can be used, and it's 00:13:00protected from the rain. So, these kinds of things. Then a couple of times I have accompanied Italian couples who were going to pick up their child at the orphanage. That was the first time I was ever really abroad in a third world country setting, and I absolutely loved it. I loved just walking around Hanoi, going to the different stores, and the pho restaurants, and just walking around and being in a completely, completely different setting than what I had experienced before. With me, there was another consultant who was far more seasoned than I, who had traveled quite a bit in different places. He always told me about his experiences as well. When I came back, it was pretty clear that I wanted to do international health. Asia or otherwise. But Vietnam was really the first time that I experienced something like that, and I absolutely 00:14:00loved it.

Q: Did you kind of follow that train into your PhD program, or what did you start doing there?

GHISELLI: In PhD land, the focus was very much on statistical methods. For the first two to three years, you're focused on your prequalifying exams and classes in methodology. There really isn't much room for any specific topic. But I did pursue that in my dissertation, yes. And that I remember, because it was based--was using Tanzania census data, and data from demographic and health surveys from Tanzania, and looking at different types of contraceptions and their impact on fertility and under-five mortality. And then recalculating population projections for Tanzania if we assumed that different proportions of the female population used each type of method. I also got to travel to Tanzania 00:15:00to do focus groups, interviews. I did seven in villages in northern Tanzania around Lake Victoria, and around the Kilimanjaro area as well. I was working with a local NGO, so when they would have a project I would set up my focus group on the side. It worked out really well. I had a very, very supportive advisor. He allowed me to go to Tanzania for three months during the last year of my PhD. He just said, I want a final draft by this date. We made it work. By the time I got back I was able to finish it off and present the weekend before graduation.

Q: Great.

GHISELLI: Yeah. But it was on a fixed timetable, and it worked out really well. That was also my very first time in Africa. That too--Tanzania is a relatively easy country for a first-timer in Africa. I was well supported. The scenery is 00:16:00amazing. No words can describe that. It just made work in Africa seem possible, and exciting and something that I really want to do. Of course, seeing what the NGO was doing, you can also understand the depth of the problems in other areas as well. It was obviously a lot of work to be done. So that was my first experience in Tanzania. I went there for the first time in 2010, July and August, and then went back in 2012, January through March. That's when I finished--I did collect the data for my dissertation and finished it off. Always in the Arusha, Kilimanjaro area in the north, with one quick trip down to Dar es Salaam.

Q: What did you uncover with your dissertation?

GHISELLI: That the pill seems to be the most effective contraceptive method in 00:17:00this context, simply because along with injections, it is the method that can be easily [taken]--does not need to be broadcasted. It can be hidden, can be taken in a very private manner. Indeed, with my population projections estimates, if a certain proportion of the female population were to use pills regularly and consistently, then you would see a significant drop in the population. Of course, with all the caveats and assumptions that come with these kinds of mathematical modeling, but it was something that I thought was quite interesting. And again, I had a very supportive advisor who helped me through all the different methods, and I think it came out something quite interesting.

Q: What was the name of your advisor?

GHISELLI: Dr. John Michael Oakes, of the University of Minnesota School of Public Health. Great guy.

Q: So what happens then in your life?

GHISELLI: I was in talks with CDC. I had seen an announcement, and for the life 00:18:00of me I cannot remember where I saw it, but I saw an announcement where CDC was looking for French or Portuguese-speaking epidemiologists. I had studied French in school in Italy and had taken one class in undergraduate. But I still remembered enough that I could call myself a French speaker. We started--I came here to Atlanta the first time--there was one of those career fairs, where you interview with a bunch of different branches and offices all at once. You know, fifteen minutes here, fifteen minutes there. The two that were most successful were the Global Immunization Division, specifically for polio eradication, and then the other one was STOP, Stop Transmission of Polio, a volunteer program. The STOP program seemed really interesting. Obviously I was going to go for the 00:19:00two-year, fixed-term position with GID. But once we continued talking, they said, we're really interested. You seem to have all of the qualifications. You're finishing your PhD. Do STOP first, just to see if this is a good fit, and then we'll talk again. So I applied for STOP, and about a week after leaving Minnesota, after graduation, I was in Atlanta. It all happened very, very quickly.

I was here in Atlanta doing STOP training, actually here, upstairs. Here in Building 19. It was the first time I had met many of those who later became my colleagues in GID. But it was a two-week training on--first week is just polio eradication, and the second week is the other vaccine-preventable diseases: measles, tetanus, yellow fever, meningitis. Then I had an additional week of 00:20:00data management training, because I had been selected as a data manager. The STOP program has three different positions. The one that is most--most people end up being field epidemiologists, seconded to WHO. I was one of maybe ten or twelve who had been selected to be data managers, also for WHO, just because we had data skills. Of course, coming from a PhD program, my challenge was more learning about Epi Info, rather than actually doing the analysis that I was being required--but picked it up pretty quickly. There were no problems there. Mapping was more interesting, creating maps and Epi Info. But you learn that, too. Then the third category is communications, and there you are seconded to UNICEF [United Nations Children's Fund] country offices, not WHO. But I had applied for the data management position, and indeed I got it right away. So the 00:21:00additional week of training was for data management on Epi Info, creating maps, creating a presentation, interpreting data, data specific to the [Global] Polio Eradication Initiative. There are specific indicators that you need to calculate, and you need to understand what disease indicators mean and how you want to tailor your response based on those indicators. So a little bit of training on that. And I was assigned to Mali. The idea was that I would travel to Mali for five and a half months, being a Francophone country, and I would act there as a data manager. So in June 2012, about a month after I graduated from PhD school, I traveled to Mali.

I arrived, no issues, start working. The first thing we do is not very specific to data management, but it is training the national consultants who will be 00:22:00working with us on polio eradication. Then I was assigned to the city of Bamako as my area, while the others were assigned to the different provinces. Then, just travel through the different clinics and do active surveillance. Review the medical records, talk with the healthcare providers, see what their level of knowledge is. Do some formative supervision. Do a little bit of a refresher if need be. Then set up goals and the time for the next visit. Now, all of this was happening in 2012. There was a war going on in northern Mali. Indeed, many people have already been evacuated. United Nations are still there. But the other part of my job for the time I was there was also helping out with the response, calculating some indicators on other diseases, especially cholera. I 00:23:00did that a couple of times, and then beginning of July I was evacuated as well. It was the time when there was the coup in Bamako. The prime minister was there, and the president had just returned to town after having been bloodily beaten, had to go to France to seek medical treatment, and now he was back. You had the general who had done the coup and the president in town at the same time. It was thought a very good idea for the Caucasian American woman to leave. Unfortunately, my other colleagues who were African-born, they stayed and they completed their mission. They were fine, and they never went in any area where there are any issues. But I was the only one of the group to be evacuated. And it was decided that I would go to Gabon, to the Sub-Regional Office for Central Africa, and continue my volunteer position there as a data manager. The problem is Gabon has very restrictive visa rules. I couldn't travel directly from Mali 00:24:00to Gabon. So I was sent to Burkina Faso, to Ouagadougou, to wait for my visa there. I already had a visa for Mali, and that would allow me to enter Burkina Faso easily, which is right next door. So I stayed in Burkina Faso for three weeks, waiting for the visa for Gabon. Pretty boring. I got to watch the London Olympics a lot. But then, finally, I was able to go to Gabon.

Q: Can you tell me how that all felt, being in Bamako at that kind of strange, critical time, and having to evacuate and leave?

GHISELLI: Up until the time they told me about the evacuation, I was doing fine. The city was functioning normally. All of my colleagues were deployed to different provinces, but all were below the buffer zone [Mopti province] that separated the North from the South. We weren't really seeing any military in town, so I wasn't feeling particularly threatened. Then when the order for 00:25:00evacuation came, and it was just me, I started to realize how visible I am walking down the street and how much people do notice me. This is something that I've kept on feeling throughout my missions in Africa, just how--not in a threatening way, but just how--being conscious of how visible I am, and how much people do take notice of me. So at that point, with the evacuation, it started to get a little bit scary. Not because anything concrete had changed. It was just my focus of knowing that, okay, I'm visible, I could be a target. Also because in a lot of the security briefings that we were receiving, the security officer was saying, "Try to be inconspicuous." I was like, either I wear a burqa or it's pretty obvious. So it was pretty tense, and I was evacuated forty-eight hours after I was told to leave--that I was told that I was going to leave. Those forty-eight hours were pretty intense for me. I was very happy to get on 00:26:00the plane. Indeed, again, there was no real reason to be concerned. The ride to the airport was very smooth. I got on the plane with absolutely no issues. It was just this idea that I was visible, and that I was not--there was no way to make me inconspicuous. Getting to Ouagadougou was much more relaxing. It was actually very, very easy to be there. My problem there was boredom because I didn't have much to do, and I can't walk around a city like that. So I was pretty much confined to the hotel.

Q: How long was that again?

GHISELLI: Three weeks.

Q: That was three weeks.

GHISELLI: Three weeks. So in the grand scheme of things, not that long. And I was very comfortable, as well. So again, I watched a lot of the Olympics. [laughter]

Q: So what happens from then?

GHISELLI: From then I finally get to Gabon. In all honesty, when they told me 00:27:00about Gabon the first time, you're going to Gabon, I was like, huh, okay. And then I go back to my desk and Google "Where is Gabon?" And "What language to they speak?" And "What is Gabon?" Because I had maybe heard about it once at some point and I don't remember when. So I find out that Gabon is a pretty small but pretty rich country. They're Francophones. Very quiet, very peaceful. Well, not since two days ago, when--they're having riots right now because the president has won reelection and there's big questions. So for the very first time ever, I'm seeing pictures of Gabon, of Libreville, the capital, in actual flames. Which we never thought would happen. All my friends are fine. We've managed to get in touch. But before that, I would have said that Gabon is a very, very, very safe country. Now there's a lot of unrest.

But when I arrived, it was completely different. You know, it's by the sea. Beaches and palm trees. People were quite happy to have an extra data manager. No one ever says no to a data manager. So it was a good introduction. The job that I had was specifically for polio eradication, but working with one of the two data managers to calculate the indicators for every week. So the Sub-Regional Office for Central Africa monitors and supports ten countries in central Africa. Those are Chad, Cameroon, Central African Republic, Burundi, the Democratic Republic of Congo, Congo, Gabon, Equatorial Guinea, Angola, and São Tome and Principe. Every week, we received data from these ten countries. The data on polio, on AFP, acute flaccid paralysis surveillance. Which is our way of 00:29:00monitoring the situation and identifying any polio cases. We received the data, we'd compile it, and we sent it over to the AFRO office in Brazzaville. We'd do this every week. We'd calculate the indicator, the specific indicators for polio, and then we'd talk with the countries to address data quality issues and see whether there is any missing information. We'd just make sure that all the graphs and tables and maps are updated for the weekly sitrep [situation report]. That is what I've been doing. I saw that the work was very laborious and repetitive, so I was trying to make it a little bit more automatic. Writing scripts and trying to move beyond [Microsoft] Access and Excel. I was not successful in moving beyond Access and Excel, but in their way they work quite well for the tasks required, so it was just a matter of producing the graphs and 00:30:00tables a little bit more quickly, updating them a little bit more quickly than just taking a week to do it. Life in Gabon was very quiet and also a little bit boring, just because I didn't know anyone outside the office. But it was also a very good introduction to WHO life, understanding the structures, the hierarchies, how data flow, and the deadlines, the timelines, who are the important people at which levels, and how to make requests for data without demanding them. In that sense, it was a very good four months.

Q: Any important lessons about WHO life that you can remember on the spot?

GHISELLI: The hierarchy. How important hierarchy is, especially in WHO, especially in AFRO. There are some people to whom you will never move to the 00:31:00informal terms of addressing them, and not because they feel particularly pompous. It's just because that is the respect that the position demands. Then there are specific chains of command when it comes to information sharing. Who gets the information first, who is cc'd, who is copied. Sometimes who is copied is more important than the content of the email itself. Oftentimes, if not always, who receives the information is more important than the information itself. So being able to, in a relatively junior position--I was allowed to make mistakes, and because I wasn't in a position to make big ones--starting slow, starting as a volunteer, to be able to understand these kinds of structures and how the information flows and to whom it needs to go first, and how to request 00:32:00information without sounding demanding, which is also quite important because country offices have very high opinions of themselves. And AFRO does as well. And the IST is in the middle. And IST, by the way, means the Intercountry Support Team. It's the Sub-Regional offices, and AFRO has three. One in the west in Ouagadougou, one in the central in Libreville, and one for the southeast, which is in Harare, in Zimbabwe. So those are the key lessons.

Q: Those are the key takeaways?

GHISELLI: Yes. And they're still valid today.

Q: Gotcha, noted. How long were you in Gabon?

GHISELLI: For a total of four months.

Q: Four months. So until--

GHISELLI: Until December 2012. And then CDC and I spoke again and said, yes, you are ready for the GID position. Let's start the application. And that lasted a year. So--

Q: The application lasted a year?

GHISELLI: To get me through and finally hired lasted a year. I don't think there 00:33:00were any particular holds. It's just that I was being hired for this secondee position. So not only do you need to get me into the CDC system, you need to have me vetted by WHO so that everyone in both agencies has full agreement that, yes, I can be deployed as WHO staff. Not as a consultant, not as a contractor, as staff. And that I can go there. And the position was for IST, Central Gabon. So I was going back to the exact same office, so that helped quite a bit because everyone knew me already. It was already clear where in the group I would fall. Again, hierarchy. Everyone was comfortable with that. I don't think there were ever any problems with having me, having my particular application accepted, it just took a year to get it through.

Q: What were you doing in that year?

GHISELLI: I was in Philadelphia. Because the process moved in fits and starts, I 00:34:00never knew exactly when the next big step was going to be. So I asked for any kind of job at the Philadelphia Department of Health. I just showed up and said, "I have a PhD. I'm willing to do volunteer work, just give me something to do." So I was working on the hepati--on the HPV [human papillomavirus] vaccine. Specifically, looking at rates of acceptance between boys and girls in Philadelphia, and by different age groups, and seeing who was the most accepting. But that lasted for a year. Because it was a volunteer position, temporary position, I don't know how successful it was, but it kept me occupied for a year. Then finally, on December 29th, 2013, I got hired by CDC, GID.

Q: Hooray!

GHISELLI: Finally. Yes, indeed. Absolutely. I was thrilled. I was thrilled. And 00:35:00the position was to go to Gabon.

Q: To go to Gabon.

GHISELLI: Yes.

Q: So tell me how that proceeds.

GHISELLI: So I spent about three weeks here in Atlanta, just doing paperwork and trainings, and processing. Then I got sent to Brazzaville for a couple of days to meet everyone there from the Polio Eradication Initiative group. Got sent to Geneva for a couple of days to meet everyone at that level as well. Then it was all a matter of packing up and shipping out. I arrived on March 4th, 2014. After a long process. But I was finally there.

Q: How were the first few weeks? Were you reacquainting yourself with people you knew?

GHISELLI: I had had the opportunity of going to Gabon a couple of times for maybe a week or two during that year, during 2013. So people kept me on their radar, although they were quite happy of me going. But my very first 00:36:00mission--hardly had settled in, definitely had not received any of my furniture yet, didn't have a house yet. But two to three weeks afterwards, I get sent to Equatorial Guinea because they had discovered cases of wild poliovirus in Equatorial Guinea. Equatorial Guinea is an interesting country. It's the only country in Africa that speaks Spanish. I got sent because Italian and Spanish are kind of the same thing, right? That, but also they had sent Francophones before with no apparent problems. But Equatorial Guinea is a country that is even more close than Gabon. Americans and Chinese can enter without a visa, which is our saving grace. Otherwise, it's almost impossible to get a visa. It's a very, very oil-rich country, which would explain the visa exemptions. And is a country that is extremely small, about nine hundred thousand people all told. 00:37:00They will tell you more, but it's not quite true. And a very, very rigid dictatorship in the country. It's not a country where you can come in and help out the best way you can. There is a specific way of doing things. At first the country didn't want to admit to have polio cases and then wasn't interested in doing vaccination campaigns.

It was two months of learning Spanish while putting together three national vaccination campaigns for children younger than fifteen. Fortunately, WHO sent its absolute best consultants who could speak Spanish, which in AFRO is not that many. They all came from Angola, basically. But they scraped together the consultants who did speak Spanish or could understand it, and we had some pretty stellar people, which is why we were able to do three campaigns in two months.

Again, the country's not very large. It takes about three hours to cross it one way--from one side to the next. The capital is on an island, and the rest of the country is on the continent. So logistically, even transporting vaccines is incredibly difficult. The government [stays] six months on the continent, six months on the island. It's anyone's guess which part of the government is on which side of the country at any time. It was incredibly challenging and very, very stressful. But it was also--if we have to call it baptism by fire. Because after that, I came back and everyone knew I had done well and under recognizably difficult conditions, objectively difficult conditions. So it was a good introduction. It just solidified my role in the team and just made me a team 00:39:00player. I think it's from there where you start seeing how my secondment was a success. Other secondees have not been so fortunate to have these kinds of opportunities. Some of them left before their two years, some others were never really quite integrated. I got integrated very well and very quickly. Of course, it helped that I had had four months beforehand with this same group of people, but still. It's good to have these opportunities to show that you want to be part of the team and actually succeed. So that was my first mission. Quite an intense one.

Q: Excuse my ignorance about the wild polio outbreak in Equatorial Guinea. What became of it?

GHISELLI: There were five cases. One case of wild poliovirus is considered an outbreak. They had five cases between April and June of 2014. When you have one case, it's an automatic emergency at the highest level. It's a public health 00:40:00emergency of international concern. It's one of those things for which Margaret Chan and Dr. [Thomas R.] Frieden get called up in the middle of the night. It's that kind of level. Because we're very close to eradication, so any case is a serious concern. We vaccinated everyone younger than fifteen, and in all honestly, anyone who asked for it. But children younger than fifteen, we visited all the schools. We went door to door to vaccinate children. I was even stopping people in the middle of the street and was like, show me your fingers. Because once a kid is vaccinated, you use an indelible marker to mark his pinky, so that when you do an assessment of the campaign, you just ask the child to show you his hand, and you know whether or not he or she has been vaccinated.

A lot of logistical challenges of getting the vaccine in the country, getting 00:41:00the markers, getting the vaccinators trained and everything. A dose is just two drops in the mouth, so it's very easy to administer. You still need to find vaccinators. That was one of the challenges. We used medical students from the university, but it's hard work. It's very hard work to just walk around under the sun, vaccinating people. Obviously not everyone wanted to do it, but we needed everyone. So a lot of convincing as well. But they have not had a case since, and they do vaccination campaigns routinely, maybe a couple times a year, but just for children younger than five now, which is the standard.

Q: What year do you return to Gabon? Or not year, what month?

GHISELLI: I returned at the beginning of June.

Q: Beginning of June 2013?

GHISELLI: 2014.

Q: 2014. I should have asked year.

GHISELLI: I arrived in Gabon on March 4th, 2014. Immediately got sent to 00:42:00Equatorial Guinea for two months, and returned about the beginning of June.

Q: That's right, because it took a year. Okay.

GHISELLI: It took a year. It did take a year.

Q: So what happens then?

GHISELLI: A bunch of smaller missions. I spent a couple of days in Cameroon giving a lecture at the university in Douala on polio eradication. They had asked for someone. "I'll go, I've never been to Cameroon." So just a couple of days there. In July I spent three weeks in Burundi, in Bujumbura, helping organize a training session. Each country has a national polio expert committee, and these are the national experts. Physicians, university professors, technicians, logisticians, who decide whether or not a case of polio that is indeterminate in the lab is actually a case of wild poliovirus or not. These are 00:43:00the people who sit down and as a committee review each case and decide whether or not it meets the criteria for it to be a confirmed case of wild poliovirus, or vaccine-derived poliovirus, that too. So central Africa had not had a training in a while, so we went to Bujumbura in Burundi to organize this training. Beautiful country. My direct supervisor, is actually from Burundi, from Bujumbura, so he was just driving us all around and showing us his high school and took us to his house. Because when he was thirty-eight he was the minister of health of Burundi, every time he comes, they would just roll out the red carpet for him. So the last evening, they had traditional Burundian drummers entertain us, and it was amazing. It was just such rhythms, and such colors. So 00:44:00that was a great experience.

Then in August, they send me for three weeks to the Central African Republic, which was interesting because at the time, during the civil war, no US government employee could go. So I, as WHO, I went. There was no [US] Embassy at the time. My colleagues at GID were very excited because finally someone could tell them what is happening in Central African Republic. I was there to help organize the training to review the micro-plans for the upcoming polio vaccination campaigns. Micro-plans are the very, very detailed sketch of where each team is going to go each day to vaccinate how many kids. To review those microplans, make them more detailed, more effective. When we were there, the last two cases of polio in central Africa were identified in Cameroon. It was right on the border with Central African Republic. Hours of panic, thinking that 00:45:00the virus had come from Central African Republic into Cameroon. But it turned out to be a strain of Cameroon. But it was among refugees from the Central African Republic, and it was right on the border. So we planned a massive multi-phase vaccination campaign right on the border and then extending it to the eastern part. With all the logistical nightmares of organizing a campaign in a country aflame in civil war. But the country office there is amazing. They do such good work. They manage to do a good job despite all of the difficulties and not having to go to work some days, just because there's unrest in the streets. They keep it going under very difficult conditions. I was very, very happy to be able to help out there, because also it's a country--Bangui is the capital, and 00:46:00we were there. It's something that you never hear on the news except for very bad events. Yet you find such a welcoming country. It seemed like a very easy country office to work with, which is not the case always. Admittedly, I would have liked to stay longer, but three weeks was as far as I could push it. But my colleagues at GID were very excited that someone was there. We had a conference call, "So what's it like? Who are the partners? Who is there, and what are they doing?" But we also went to the IDP camps, the internally displaced people camps. Especially the ones around the airport. There were a lot of people who had been displaced from the east and had arrived in Bangui and just settled around the airport. When you arrive, the first thing you see when landing is French military blocking the access to the runway, because there's so many 00:47:00people squatting around the runway that they have to stop [foot] traffic for a moment to let the airplane land and then let them go through. I had never seen a camp. It was pretty awful. Red Cross, Doctors Without Borders and CARE were there providing assistance to the camps. They were providing all the routine vaccinations, and water was a big issue, but they were dealing with that as well. You could very much see people who had arrived with nothing, and trying to set up--I remember one tent made out of a rice sack. You know, something like that. And it's all around the airport, and no one knows for how long they're going to be there. And MSF [Medecins Sans Frontieres] is trying to do something. MSF, Doctors Without Borders, is trying to do something in very limited conditions, and the French military are all around you. The day I left they were 00:48:00in battle gear. That was a very surreal experience, having to go to the airport with all these French military in battle gear all along the road, and on the radio I'm hearing about Gaza. And it's like, okay, that's interesting. I'm hearing about war in Gaza, and war is literally outside my window. So that struck me as an incredible parallel. One that hasn't happened again, fortunately. But I had never been in a situation where conflict was so clear. Then our airplane was delayed a little bit, but we made it out with no issues.

Q: When did you make it out?

GHISELLI: When was it--at the end of my three weeks? So it must have been the middle of August 2014.

Q: I know you have tons of things to focus on at this point in Central African 00:49:00Republic, but are you also hearing things about Ebola at this point?

GHISELLI: You know, it's very interesting because we hear things about Ebola, of course. We were in Brazzaville when Ebola was declared an international emergency. But we're focused on polio. We have a polio outbreak going. So we're really not hearing all that much. Ebola's a different branch. We're not hearing all that much. And indeed, getting information out of the US newspapers--my friends and I are just looking at each other because we hear what seems to us hysteria in the US, while here in Africa where we're much closer, no one's really concerned. The US Embassy, the one time they asked me to do something was to learn a little bit more about the Ebola preparedness plan for Gabon. So I go and talk with my [WHO] colleagues. And, by the way, I'm in the Sub-Regional Office for Central Africa. The Gabon country office is a completely different 00:50:00office. We're on different floors. So I know as much about Gabon as I do about Chad, or DRC [Democratic Republic of the Congo], or Angola. Gabon is not my bread-and-butter daily task. So I have to go downstairs and ask, what are you doing? And the response is, not that much. Even though Gabon has had four outbreaks of Ebola, they have all been out in the bush. Very small villages. Nothing much has happened. You just cordon off the area, and when it dies out, it dies out. The military, yes, they have been put on alert for the cordoning off, but how many beds do we have in Libreville? Four or five. Alright. There is the laboratory in Franceville, which is on the other side of Gabon near the border with Congo, which is a very well-known laboratory for tropical diseases. It's one of the few laboratories in Africa at the time who could do Ebola testing. So obviously everyone's focused on Franceville as well. But this is 00:51:00just because I'm asking the questions. In my day-to-day work, Ebola doesn't really figure. It is only, I think, when I mention--I'm starting to hear people being deployed. Because again, in AFRO we were the only ones to be deployed. It wasn't a matter of being a volunteer. And I start hearing about colleagues being deployed, organizing trainings. Going there mostly as tech support, or admin support. A couple of them are in coordination positions. But again, it's very faint. I just hear people being deployed. I don't really know them. But I know they're going to Guinea, because they speak French. We're a completely Francophone office. There's hardly any English spoken. So one day, when I'm speaking to my supervisor, the one from Burundi, at the end I just say, "And, 00:52:00you know, if you ever need more volunteers for Ebola, I'm willing to go." And he's like, "Oh, you're a brave one." Okay. So I'm in Equatorial Guinea again when I get the news that I'm actually being deployed for Ebola, and it's to Sierra Leone. It was like, okay, when do you leave? December 24th. I had plans. You're being deployed. I mean, it's--you're being deployed.

Q: Right. What were your plans?

GHISELLI: Going home to the [United] States for Christmas. Five days before, I have to call my parents and say, not only am I not coming, I'm going to do the Ebola response. At this point, I'm not in the best of spirits because no one likes to have Christmas cancelled. But, fine. It's a deployment for a month. Because AFRO is deploying its personnel, we only go for a month. Volunteers, 00:53:00it's a different story. But because we are made to go, a month is as long as they will make us go. Six weeks at the most. We're staffers, we're not even consultants or contractors. We also have day jobs that need to continue. So a month, six weeks, is as much as we're allowed to go. Then I learned that training is in Brazzaville on December 26th. So, fine. I rearrange all my plans. But also one thing that struck me very strongly was that, before leaving, there was no training whatsoever. No explanation whatsoever. It was just like, you're getting on a plane and you're going to Ebola Country. Here's your itinerary. They'll do your training in Brazzaville. Okay. So after spending a not-so-happy Christmas 2014 in Brazzaville at the [Brazzaville Beach] Hotel [near the AFRO 00:54:00offices], I get to the Brazzaville--the AFRO office. Because it's right after Christmas, and because this is Sierra Leone, they have to scrape together the three people who actually speak English to give us a training. I was there with two other colleagues from Tanzania, from the Tanzania country office. They give us a training, and it's pretty horrible. It's about three PowerPoint presentations that they just read in very bad English. Didn't give us any context, didn't give us any information of what it's like on the ground, the kind of protective gear that you might be getting. What they did give us was a whole bunch of vaccinations, including a cholera one just because, and a med kit, which was quite good. But I'm hearing about my CDC colleagues and all the stuff that they're getting. The PPE [personal protective equipment], and the hours of training, and the visit to the health clinic, and all these things, and 00:55:00I feel like I'm, you know--I'll find out when I get there.

Fortunately I had a colleague from GID, Liz [Elizabeth] Bell, who was kind enough to take my frantic phone call before I left Gabon, and just like, "Just tell me what's happening at the airport. Am I supposed to touch nothing?" I didn't even know about the chlorinated water. I knew nothing. So she talks to me for about an hour and promised me to give me all the information that the CDC teams had received and things like that. Also because I know that the CDC teams are staying at the Radisson [Blu Mammy Yoko Hotel]. No idea where I'm staying. No clue. Am I staying in Freetown? Am I going elsewhere? What is my role? No idea.

I calm down, and after a very long trip from Brazzaville, Pointe-Noire, always in [the Republic of] Congo, Abidjan in Ivory Coast, and then finally 00:56:00Freetown--connections in Africa are pretty bad. After a very long flight, we finally arrive in Freetown. Of course, with Liz's explanation, everything works exactly as it's supposed to. You get picked up by the WHO's driver and taken to your hotel, which is a perfectly appropriate hotel. It's not the Radisson, but it's perfectly appropriate. All the other WHO staffers are there. And it's fine. It's fine. Then when we arrive the next day in the country--and the country office for Sierra Leone, of course, is run over by the yellow fever--excuse me, the Ebola responders. The country office folks are in a corner doing their own things. But it's clear at that point there has been someone who's put some thought into the welcoming package. Because we're being moved from one session to the next. It's not very, very detailed sessions, but at least we're in country. At least we see that life continues in Freetown, so it's not the death 00:57:00zone that your imagination could lead you to believe, especially if you haven't received any information to the contrary. We don't get very specific information, but we have enough context to absorb the information that we're being told and put it into context.

Then when it comes to our roles, they don't even have our CVs [curricula vitae]. We just write down like four or five key things. Then they call--they--we hand them all over, and they call us in one at a time in a room and tell us what they're thinking for us. Okay. So--alright. I walk into my room--to the room. And they said, "We're thinking for you to send you as field coordinator for Kambia District." I was like, "Okay. Kambia. On the border with Guinea. Yes, 00:58:00okay. Field coordinator, what does that mean?" "You're kind of the WR, the WHO representative for that district." "Okay. Interesting. I think I know what that means." The decision was made like that. I think multiple things had to do, factor into that decision. One, I had a PhD. But two, I was AFRO staff. And AFRO staff tends to get priority on the coordination positions, coordination and leadership positions, just because we are the ones from the home turf. Unless there's something particular, you should justify why we're not getting those positions. I like to think that my other qualifications helped as well, but I'm 00:59:00sure that that factored in as well, that as AFRO staff, I was automatically put in a--I was told later that, no, no, no, they needed someone good, and they sent you. But at the time, I thought it was just like, okay, AFRO staff and moderately competent, probably that's why.

At the time Kambia wasn't registering much of any cases. It was next to Port Loko, which was registering a number of cases, but Kambia itself wasn't registering much at all. At the time we had no idea what was happening in Guinea. So, okay, Kambia. First time in a leadership position. It seems--good introductory district. A good way--would I have liked something a little bit more difficult? Maybe. But it's a good introduction. It's a good introduction to 01:00:00leadership. I was like, okay. Of course, how many people are there on my team? Three. I was like, okay, we start small. It's not overwhelming, that's good.

The next day, January 1st, 2015, I jump in a car and I go. Three-hour drive, and I'm in Kambia. What I find there is not only my three team members, of whom one is leaving; one CDC staffer, EIS [Epidemic Intelligence Service] officer; a very small group of local staff; and then the British. The platoon with their commander, Commander Clinton Davis--Squadron Leader, I'm sorry, Squadron Leader Clinton Davis. And of course, the DFID [Department for International Development] representative Helen Richards. She's the DFID representative there. 01:01:00And that's about it. Again, we're not seeing that many cases, so yeah this works fine. It takes very little to realize that no one in this district is dying of anything. No one's dying of anything. We look at the mortality rates, nothing. So the joke is we found the fountain of youth. But in reality, that is a clear sign that surveillance is not working, just not working. So we start--I speak with my supervisor at the WHO office, Dr. Matt [Matthew] Craven. He starts sending me people, WHO staffers, consultants, some from--they're mostly consultants. Some are from GOARN [Global Outbreak Alert and Response Network]. Others from country offices. For example, we had an epidemiologist from [the WHO 01:02:00Country Office for] India. By the end we were having epidemiologists from Indonesia. The group keeps getting larger and larger, and we start forming teams. And we start doing active surveillance. We start doing contact tracing the way it's supposed to be done, [methodically]--excuse me, systematically. We're just trying to find who was supposed to be seen, has that person been seen, how many times a day, how are they feeling. Trying to give a little bit more objective measurements of whether a person is sick or not. Because we're finding, obviously, a lot of people who are saying they feel fine, and then the next day they're dead. It just keeps on going and going and going. So trying to systematize, to make it more reproducible, and trying to really strengthen this.

I think we got to the key point when a sub-district--the chiefdom of Samu, which is on the coast, right on the border with Guinea, we finally start seeing cases 01:03:00there. And indeed, it was a mess. Once you get in, once you crack it, it's a mess. A lot of secret burials. Lots of people hiding inside their houses, or getting out at night, trying to hide the fact that they're not feeling well. Just going on and on and on. At the very beginning we were still finding known contacts that were dying in their houses of Ebola. By the end, we didn't have that situation anymore. It was incredibly rare to find [any]--actually, I don't think we had any, by the time I left in March. When we had known contacts who were dying of Ebola, we were able to evacuate them quickly. We improved--we revamped the entire system and made sure that the ambulances were there. We had the laboratory in Port Loko, which was forty-five minutes of good roads away, but we managed in the end to get a laboratory in Kambia as well.

What else did we--oh, we just launched these "assaults." By that we just mean 01:04:00going out into the villages and actually doing active case search, not just going to the houses of known contacts, but going to every single house and asking how people are doing, asking to see everyone. We did a huge, huge push to improve the materials being given to the houses under quarantine. Because when we arrived there were times when the materials and the food would arrive two to three days after the start of quarantine. And of course people leave their houses, they're hungry. So we improved that greatly. Within twenty-four hours, you got all the food that you needed. We were going to do weekly distributions, not the three-week lump sum. We were going to do it every week so that you don't use it all up, and then we have to say no, no more for you. We gave cellphones, we gave solar chargers. We gave--by the end, after I had left, managed to give 01:05:00every single possible item that a person could need in their house to survive three weeks without having to leave.

Unfortunately, we were never able to get rid of the guard outside of the house. Which created a lot of problems, mostly because people knew, sometimes, that the gun was not loaded. One thing that I'm quite proud of is that we never did like Port Loko did, which is contact tracing with an armed guard with the team. We never went there. We instead put a social mobilizer. That was something that we felt very, very strongly that would not help. Because people were already running every which way, and we didn't think that armed guards would help any, especially considering the history of Sierra Leone, with the civil war. In all honesty, already many of our local staff had been child soldiers. So, 01:06:00for--already explain that you don't go into a village screaming. You talk to people. How do you speak to people, that was all things that had to be explained and taught. Because a large portion of them had been child soldiers, had lost family members. It was actually very hard to hear some of these stories because it was just harrowing. It happened only ten years ago. But it was also something else that we needed to keep in mind, that when people enter a village and they're strangers, people know nothing good can come out of it. If you come in in a white spacesuit, that just makes it even worse. The people with whom we were, the local staff, were already being seen as kind of the enemy.

Also, in Kambia, very interestingly, it's the hotspot of witchcraft in West Africa. So we had to deal with a lot of witchcraft. With this one village called 01:07:00Bankfi, which was, according to popular lore, populated with wizards of every age. All of them are wizards. And the way you transmit Ebola is through a witch gun, which is a wooden stick they just point to the person and curse them with Ebola. Our local staffers wouldn't go near that village. They just wouldn't go. It took a long time for them to explain to us why. We had the paramount chiefs go there and explain things, and how this is really a disease, it's not witchcraft. That was a nut we were never able to crack, Bankfi. We knew that there was infection in that village because we knew that a lot of people were travelling to that village obviously to seek a cure. Then they were leaving and dying in the villages all around. But in Bankfi itself, we never got a 01:08:00notification of death. We just knew that everyone had gone to Bankfi and come out and died, but no one ever died in Bankfi of anything. This is a time when all deaths have to be notified, of any kind. So we just know that there's something going on in this village, and we monitored frequently.

The other interesting thing about Kambia, it's on the border with Guinea. When I arrived, one of the first questions I asked is, what is the name of the district on the other side in Guinea? No idea. Is there a road that goes to Conakry? No idea. So one of our biggest challenges and great results have been to build relationships with Forecariah in Guinea, understand what they're doing, and setting up what I think is a very, very good cross-border surveillance system, 01:09:00where every known movement of suspected cases is reported. It's followed up on each side, and information is sent back to the other side. It took a long time, but we even got a memorandum of understanding between Kambia and Forecariah. An official one. This was my last week in Kambia, when we had the ceremony at the border. But when I arrived, we had no idea what the other district was called, and it turned out to be Forecariah. But Kambia, by the end it was a completely different picture than when I arrived. The beginning, there was hardly anything happening, a couple of cases here and there. By the end it was the most problematic district in Sierra Leone. I don't think it was because the situation had gotten worse, it's just that the surveillance system had gotten much better.

By the end we had a huge team, seventeen for WHO. The British contingencies remained the same, but local staffers had increased as well. CDC team had increased as well. We were bringing in partners from all sides. We were trying to build an ETU, an Ebola operation--ETU--emergency [or Ebola] treatment unit, in Kambia, just so that people could remain closer to their family members and people didn't have to travel that far to get information. We set up a relationship--a [family] liaison officer, who had the horrible job of informing family members of their loved ones' status or death. A local staffer who did it admirably. His job is one that I do not want, and he did it with such grace. 01:11:00Having to deal with the burial teams and making sure that they were properly trained along with the ambulance drivers, and making sure that all procedures were being followed. Constant, constant, constant training that ourselves and CDC gave as well. Just working with all the partners. Our treatment unit did a massive switch. It used to be Partners In Health, and by the end I think it was CARE. But having to manage all of those, and having to send people to Port Loko in the meantime with all the logistical issues that come with it as well, and then bring them all back to Kambia. And Kambia has the very, very unfortunate position of being far away from everything, so supply lines were incredibly stretched. Supply lines arrived at Port Loko, where the tent city was set up by the Danish government. The food, the fuel, everything was arriving [there]. In 01:12:00Kambia we had none of it. One of my biggest issues as a field coordinator was, where do I put these people to sleep? I have no place. There are no hotel rooms. There are no tent camps. There is no safe place where I can put these people. There's none. And by the end, when I had--when I left, a couple of people were sleeping in Port Loko and coming in every day because there just wasn't any room. Food, there wasn't that much. Lots of chicken and eggs and potato chips. We only had a gas station to buy anything else. So we lost a lot of weight.

Q: Where were people staying in the meantime, while you figured this--this rooming situation out?

GHISELLI: No, the thing is that, as they arrived, I would just book all the rooms of the two hotels. Of course, we're not the only ones who are there, and 01:13:00the local staff--and these are the only two hotels that are approved by the UN [United Nations] and by USG [United States government]. But the local staff can stay elsewhere, so that provided us with a little bit of respite. But it reached a maximum capacity in about--at the end of February, so at the end of my second month. And I said, absolutely no more people. I don't know where to put them. For a time we stayed stationary, but then the people kept coming back. Because, you know, you just receive like--there's a whole group of people coming in from Indonesia. You have to assign them to the provinces, the districts, and one of the districts must be Kambia. So that's when they start staying in Port Loko. And office space as well. Because we were all in one room in the DERC, the District Ebola Response--Team?

Q: Center?

GHISELLI: DERC, yes, center. When we were a group of fifteen, twenty, that's 01:14:00fine. But now we're sixty. I had to order [World Food Programme] containers to constitute office space for us. Which means that, unfortunately, WHO moves out of that [operations] room. And one of my strong points as field coordinator, was I am always in the room. I'm always in the middle of things. I'm always available via phone, in person--which was terrible for me, because I always got interrupted. But I knew everything, and I was able to get in touch with everyone. So I was very hesitant to move WHO out of the room, but it just became a point where we just couldn't. There was absolutely no space for us to be. I know that after I left, and the containers were set up, the main WHO staff stayed in the containers, but the field coordinator kept working in the room. That was a good compromise, but--yeah.

Q: There are a lot of things that I want to go over at this point. Do you mind 01:15:00if we take just a short break, though?

GHISELLI: Of course.

[break]

Q: Can you tell me again what day you arrived in Sierra Leone and what day you left?

GHISELLI: I arrived on December 28th, 2014, and I left on March 31st, 2015.

Q: Gotcha.

GHISELLI: And I arrived in Kambia on January 1st. It's a good start to 2015.

Q: I think the first question I want to ask is, what--what was the attitude of staff and partners like when you arrived in Kambia, especially regarding that lack of surveillance? Was there recognition of that, or did you have to kind of introduce this concept that, when we're not seeing cases, that may actually be 01:16:00the greatest problem of all?

GHISELLI: I think on the one hand people were still hoping that Kambia had dodged the bullet. But on the other hand, everyone recognized that there were issues. The problem of weak surveillance was one of many that people were starting to see. Like, we're very few here, we're not very well organized, our meetings are not very well organized, they take a really long time. So these initial issues were the problem, and surveillance--we could talk about surveillance only when the first ones had been fixed. So the first weeks were to set up the meetings, make them a specific duration, what are we going to talk about during these meetings and how do we follow up. So once those pieces were in place and we actually had teams with plans, then we could start talking about surveillance. One big point was that all our efforts had been reactive to that point. We have a confirmed case, alive or dead, and we investigate. How do we move to a proactive place where we know where we're going the next day, we know 01:17:00what we want to accomplish, who we want to see and what kind of results we want to bring back, and how do we discuss those, so that we can inform the activities of the next day? We were able by mid-February to do that. Actually, our "assault" was the first time we could actually plan out, week by week, where each team was going--day by day for each week, where each team was going, to which villages, and why we picked those villages. It took a lot of effort, but we got there in about six weeks. But at the beginning, people were--hope I dodged the bullet, and we have so many other more basic problems to solve before we start talking about surveillance.

Q: Can you describe some more of the--I know you arrived and there were three people, one of them was going to leave, for WHO. Who were they, and can you describe in a little more depth other people that you worked with a lot?

GHISELLI: Sure. In my WHO team, there was a consultant from Tanzania. He's the 01:18:00one who was leaving, so I met him very briefly, just for a couple of days. He was a field epidemiologist, and I don't know much about his work because he left right away and didn't come back. Another one was a local staffer from WHO, so a WHO contractor, Yaya. Muhammed Yaya Jallow, who was our [social mobilization] person. The poor guy was so intense and wanted to do so much. He didn't have any basis from which to start his work, because there wasn't any real communication pillar, any communication component. He was just doing what he could, talking to people. But he didn't have any plans or any strategy. And then the third one was a consultant who had come through GOARN from Public Health England. He was with us for about a month, and he was also a field epidemiologist. He was an older 01:19:00gentleman, a physician. The stereotypical English country doctor who arrives in Sierra Leone and wants to experience everything. So he wanted to go to all the villages and ride in all the boats--obviously following the mission, but he wanted to be everywhere. Sometimes we had to redirect him and say, "No, I really need you here, even if you have been there before." That's the team with whom I started. The EIS officer with whom I was, Rebecca Levine, she was there a week or two before me. She gave me my first briefing. We worked very closely together in identifying what the issues were and how to address them. Then my biggest partner in crime for the whole duration was Helen Richards from DFID. She and I did absolutely everything in partnership. She, myself, the new military leader, 01:20:00Major Henry Dowlen from the Royal Marines, and Mike McKee, who was a consultant for DFID as well. The four of us, when I say "we," that's who I mean, the four of us. Obviously with the district medical officer and the district officer. Obviously these persons were always involved in all of our decisions. But we were the ones who put together the strategies. We proposed activities, and we were the ones to see them through. We were the ones answering all the questions and being the point persons for all the activities that happened in Kambia.

Helen and I--she was more focused on the social mobilization piece, while I was more on the surveillance, epidemiologic piece. But there were so many points of contact between the two, that we just pretty much split the meetings between 01:21:00ourselves. I like to think we ran a pretty tight ship. We interacted with many, many, many partners, almost too many to remember. We set up a number of plans and projects and strategies, and we followed them through. I think we were the ones to put together the proactive planning, so that people would know where to go two days from here, and we would be the ones selecting the villages and the teams to go to each village and who exactly did we need for a specific place. My collaboration with the British team was superb, just a well-oiled machine. With my [WHO] staffers, I was able to maintain one-on-one relationships with each one of them until we got to be seventeen. And I was out the door, and there were seventeen people, and then it became very difficult. But while we maintained 01:22:00that magic number between ten and eleven, I had good relationships with each one, just one-on-one relationships. At that point, an Ebola week is like a year, so we had been together for a really long time. I had assigned different tasks, and just following through, and one of them actually became team lead, two or three team leads after me. So there was a good continuity and we worked out really well.

But it was a diverse group of people. Because Sierra Leone is Anglophone, you get consultants from all over the world. So you get people--for example, I had a very, very good consultant from GOARN, [and] she was a university student from Germany. Then I have this field epidemiologist from India who's done polio eradication, who's very good. Fieldwork is his bread and butter. Then I have this other consultant from GOARN who's a university student. She's never done 01:23:00the field before. They're both excellent, but different strength and completely different backgrounds. I have someone who is from South Sudan. He lived in the refugee camps. So harsh field conditions [matter little] to him. And then I have other people whom this is their first time in Africa. So a very different, diverse group of people to manage. Then towards the end, WFP, the World Food Programme, integrated themselves with us to provide logistics. That was a completely different system that had to be somehow harmonized with what we were doing. That was a bit challenging, hopefully got solved by the end, but when I was there wasn't working all that well. But it was also two weeks old, so there was a lot of room for improvement. But my team members, they were extremely dedicated. No one ever refused to go out into the villages. No one ever 01:24:00[insisted] to put their safety first, as opposed to that of other people in the villages. We've always stressed safety, hand washing, no touching--we had a very strict no touching policies of--touching of anything or anyone. Everyone respected that. But no one ever refused to do something because they put their own safety first. Even when we had to go find suspected cases in the islands, off the coast, and that required getting into fishermen's boats, they went. They went, and they did contact tracing, and they did it very well. Because a lot of suspect--a lot of people who were sick were going to go hide in the islands [of Samu Chiefdom] thinking that we would never reach them there. And we did, on fishermen's boats. So, these kinds of things. I really had a very, very good 01:25:00team, and I was sorry by the end not to be able to have a one-on-one relationship with everyone. It just got too big as a team, and I was always--I never could go to the field. I was always at the DERC. So people would come to me at the end of the day, and we would talk about things. Maybe in retrospect, I should have done more team meetings. We only had one per week. Maybe it would have helped to do more, but at the time, again, the team was relatively small, so we were working quite well in that way as well.

Q: Sorry, just to clarify quick. Were you--you were headquartered at the DERC? Is that right?

GHISELLI: I was, yes.

Q: Gotcha. So can you kind of describe the communication that you had, probably with country leadership of WHO?

GHISELLI: For the field coordinators, we had one point person at the WHO country office, Matt Craven. Matt is a--he was seconded to the WHO from McKinsey [& 01:26:00Company] consulting firm. He's a physician by training, a medical doctor by training. Decided to be a consultant for McKinsey, and is now seconded to WHO. He is exactly what you need in these kinds of crises. Zero sense of humor. [laughter] Like, zero. Zero sense of humor. But you ask him a question, you have the answer. You send him an email, he responds two minutes later. You call him, he's available. It was exactly the kind of lifeline that I needed. I have a question, I have a concern, I need a clarification, I call Matt. I get my answer, we move on. And he was really my only liaison with the country office. That was his role, he was designed to do that. I think he might have had another task or two at country office, I don't know. I think that monitoring all the districts and field coordinators was plenty. But the man is a machine, so he 01:27:00probably could have done more. But he is--he's exactly the kind of man you need in a crisis.

Q: What kinds of things were you asking of him?

GHISELLI: So, for example, at the beginning, just like petty cash. How do I do this? Where do I get this? Oh, here's the letter, you go to the bank, and they give you bricks of cash about a meter high, and about a meter wide, and you put it in your car, and that's how you use to pay for fuel, like--for all the cars with WHO. It's like, okay. Or I need another vehicle. Or I need two epidemiologists. Or I want to try this strategy, what do you think? But mostly it was--I used him because it was my first experience in leadership. He was a very good sounding board for the kind of political decisions that I need to make in order to maintain smooth relationships with everyone in the DERC. When I had some issues with the district medical officers, I don't know how to approach 01:28:00something, he would help me out on that one as well. I think we spoke about once or twice a week. But it was sufficient. I never felt like I was cut off.

Q: What kind of issue with the district medical officer?

GHISELLI: He wasn't the most involved person. I think in one hand, it's overwhelming to be the district medical officer in Kambia at the time. But on the other hand, we never felt that he was fully, fully involved, or at least wasn't as participatory as we would have liked him to be. Might be our fault, maybe we [unclear], but that was our feeling. And then the district coordinator, who was a political [appointee], he tried to do too much outside of the strategy. So when Mike McKee was there, he was able to build a very good relationship with him, and he was working within the strategy. But then Mike had to leave for a family emergency, and things just kind of--it took a lot of work 01:29:00for Mike to bring him back to the strategy once he came back himself.

Q: What else is there to do besides the strategy?

GHISELLI: We were trying to decide, surveillance, how do we want to make this work, now that we're proactive? Which kind of villages do we want to go, and how do we deal with the influx of suspected cases that a good surveillance strategy would bring up? That includes: you need more beds at the ETU, you need more ambulances, you need to be able to reach these people more easily, and the roads are terrible in Kambia, and you need more contact tracers, and who are going to be our contact tracers is the--and then social mobilization, what kind of messages do we want to send out? What kind of information do we want to give that would not scare people, but on the other hand make them more willing to work with us, without completely ignoring their concerns and their beliefs? Because again, witchcraft was a very, very strong belief, and you don't want to 01:30:00dismiss it. So it was these kinds of works for the IPC [infection prevention and control]. How do you sanitize the waiting area, how do you make sure that all the healthcare workers have their hands clean--again, with the influx of patients, how do you make sure that the chlorinated water is replaced daily? Do you want to buy soap? Who's paying for the soap? Things like that. So, one--the strategy was to improve surveillance, and then everything split out in multiple, multiple, multiple areas.

Q: Gotcha. When this gentleman isn't following that immediate strategy, what is he focusing on?

GHISELLI: Oh, the district coordinator? Well, for example, his big thing was to bring a laboratory on the border between Forecariah and Kambia. Now, both Forecariah and Kambia have their own laboratories. And he wanted a border laboratory. We start pointing out, well, who's paying for it? Who's training 01:31:00them? What language? Why should people go here when each district has their own? And he was focused on that. So it sometimes was very difficult to move him away from these ideas, which, you know, are very grandiose and sound good in the papers, but it's not what we need. Just the amount of resources that would have taken away from day-to-day activities would have been huge. None of the partners were supporting that.

Our other big issues were the CCCs, the community care centers. UNICEF had seven all across Kambia. The idea is those are holding centers for the suspected cases, closer to the villages, so that their family members can go see them while they wait for their test results to come back. We have to open these CCCs, and UNICEF is doing it. And they don't have much experience in running these kinds of camps--these tents, these systems. So, you need an ambulance, or at 01:32:00least a motorcycle to take the--to draw the sample. Who's going to draw the sample? Do you have a trained person with all the appropriate equipment to draw the sample? Do you want to take them to the ETU? But then let's just take them to the ETU, and you're not taking them back. All these kinds of things. We were always against the CCCs. They were open, and they were closed, and they--not much happened in between. But it was a huge point of contention. Oh, we need the CCCs to be close to the people. Well, what service are they really providing? It's like, what kind of added risks and resources are you putting into the CCCs that could be directed elsewhere?

Another huge point of contention was the reopening of the schools. We were completely against it. We thought, because schools were being reopened all over Sierra Leone, we kept saying Kambia is in no position to reopen schools. In the south, things are going well, in the north here, they're not. You cannot reopen 01:33:00schools. We wrote a paper, we involved the authorities. We just made it very clear that schools were not to be reopened, and I think we delayed them for a while. They were reopened as well. But markets had already been shut down a long time ago. Nothing was happening. So reopening schools would have been really, really difficult. How do you monitor these kids? What do you do when one's kid is sick, or when a family member is sick, in terms of the stigma attached to it, if nothing else? How do you monitor the kid's temperature, and how do you--I mean, with the thermoflash? Is that safe enough? You're putting a lot of kids from who knows where in the same room. Is the teacher going to be willing to show up? Are the parents going to send their kids? Probably not. So why--a huge point of contention. And I think we managed to delay the reopening for a while.

Q: Who were the advocates for reopening?

GHISELLI: UNICEF, and at that point the district officer. But we thought it was more a matter of showing that something had been done in this venue, rather than based on epidemiological facts. Because we thought that at least Kambia was way behind the rest of the country. So what was applicable to the other provinces--to the other districts, was not applicable to Kambia. That was a battle that we had to fight all through my deployment there, thinking that--Kambia is behind. Kambia is behind, it's about two to three months behind the rest of the country. It's along with Port Loko and Western Area. We're behind the rest of the country. You cannot apply the same rules and regulations to these three districts. We're just not ready to move on. We're just not there 01:35:00yet. And they started taking away some contact tracers and starting to slow down the response when, in reality, it should have been pushed much, much stronger. This was something that came from the government of Sierra Leone, who wanted this outbreak to be over as quickly as possible. I'm sure partners at the national level were arguing against it. That was one thing I had many discussions with Matt Craven about. It was just like, we are not ready, we are not ready. Don't do this. I think that by taking away--we were able to retain some [resources], but some were taken away, and I think that that delayed things--delayed resolution by some months as well. Because Kambia was just behind and in no position to start drawing down the response.

Q: I'm particularly really interested in the discussions you must have had around the guards. The houses and the guards with the contact tracers.

GHISELLI: That was in Port Loko. We never did that.

Q: Right, you never did the guards with the contact tracers.

GHISELLI: No, no.

Q: That was just Port Loko. How did you negotiate that?

GHISELLI: Well, we just never put it on the table--we never made it an acceptable option to have guards on the table. I think at one point there was talk about sending in the military to do active case search. We could all picture in our heads what that would look like. That's when we launched our "assault" strategy, where our people with our own social mobilizers would do the same work in going house to house and looking for people. But we had to use that kind of military terminology, just so that--to give the impression that it was equally rigorous and equally effective.

Q: The "assault."

GHISELLI: Indeed. Indeed. But that was the only time when there was serious talk about involving the military. For the quarantine houses, we knew that that had happened at the very beginning, and we already knew that people were sneaking outside of their houses at night. These poor guards were just put there and 01:37:00told, "Guard this house twenty-four hours a day." No supplies, no nothing. Of course the poor guy needs to go find food, and--so, we never thought it was an effective strategy, but that was a lost battle to begin with, so we never fought it.

Q: And it was again government officials who were bringing up the idea of bringing in the military, that kind of thing?

GHISELLI: Yeah. And again, given Sierra Leone's history, it probably sounded like a reasonable option. It's just something that we were very strongly against. Very strongly, and we said it in every single meeting that we could. And we were able to offer alternatives to this strategy. I think they worked just as well, if not better.

Q: I'm going to have trouble phrasing this question.

GHISELLI: That's fine.

Q: Did the public--did the Sierra Leoneans trained in public health you worked with, you know, the local people--where were they on these issues? You know, if 01:38:00my government's saying something to me, I'm going to be probably biased toward wanting to follow it, but--

GHISELLI: I think we--they were part enough of the response that when we proposed something, it was clear that it was with the DMO and DC's approval, the district coordinator and the district medical officer's approval. So we didn't find much controversy. What we did find was this entrenched belief in witchcraft. So they might do things that we ask them to do, but maybe not with the same conviction as if they had not believed in witchcraft. Which, again, we're trying to eradicate a system that's been there for centuries. We've lost to begin with. So that was the bigger issue. Trying to propose something like going to these villages and looking for things, or making sure that you know 01:39:00that you are not cursed if you help us out. Those were the bigger hurdles, made bigger because this is not something you can openly talk about. It's not something for foreigners to discuss, or to be discussed with foreigners. It was only when we created a good relationship with our own local staff that we were able to even get a glimpse of what these issues are, and from there, build.

Q: Wow. So how do you--when you can't have open discussions about this, how do you learn about it?

GHISELLI: It took a long while of relationship building. For example, for Bankfi, we had no idea what was happening in this village, and it was our staffers who finally told us. But it--that was after a couple of months of working together day by day, mutual respect, mutual collaboration, that's when you learn about these things. When your local colleagues see that you take this 01:40:00seriously, you don't laugh, you take this as a consideration, and you build--try to incorporate it in your strategy. Then I think it becomes easier to talk about it, or at least to acknowledge that that is a problem in this village. Then we were able to have our--we were truly able to build a relationship with a couple of authorities in the villages, and then we would get more information that way.

Q: Did you ever reach out to traditional healers? Was that possible?

GHISELLI: We did, but without much success, to be honest. Because we were stealing their work. If a person came to us instead of to them, they didn't get paid, obviously. We never figured out a way to incentivize notification. There was talk about payments, they were talking about--we talked about certifications, things like that. It never materialized. We tried, and we never 01:41:00got enough attrition to do something. And we tried to involve the paramount chiefs. Some were more engaged than others, but we never got that full-throated support that we would have expected from them. They were the true authority in the district, because this was--they got their position from lineage. It's hereditary. There are specific reasons why these people are named paramount chiefs. Their position carries much more weight than a government that sits in Freetown. We never got their full-throated support that we would have liked to see. Some more than others.

Q: Some more than others?

GHISELLI: Some more than others.

Q: Were there any that you were able to form relationships with of any kind?

GHISELLI: Not me specifically. But the response in general. The one in the chiefdom where we were--whose name escapes me now. But in this central chiefdom [Magbema] where Kambia town was, he was the most open and interested in working 01:42:00with us. The one in Samu, where no one was dying, and had the islands, we managed to speak with him maybe once or twice. But it was clear that we were not going to get support from him, because not once did he denounce the secret burials, while the other one in Kambia town was very vocal about it.

Q: I probably haven't asked this question enough of people, but how did you find gender at work while you were in Kambia? With both international and local staff?

GHISELLI: International staff it wasn't much of an issue. National staff--it's something that happens all over Africa, and I think in Sierra Leone it was a bit stronger. In Africa, a white woman is always seen as someone who doesn't know 01:43:00much. You overcome that by being very competent, very helpful, and always working in partnership with people and trying to make them look good. It's a strategy that worked very well in my office in Gabon, and it works well overall in the African context. In Sierra Leone, I was struck how women were excluded even from the most menial jobs. You know, washing or cleaning. It was always a man doing it. I was always very surprised about that, because usually in other cultures these are lesser things for women, but here not even that. I think that the DMO and DC had some problems with white women, Helen and myself, being so much at the center of the response. Because we had Major Henry Dowlen and Mike McKee there as well to support us. Mike McKee made it a point to be kind of the 01:44:00bridge. Things never escalated to a problem, but you always--Helen and I both felt that there was a little bit of reserve towards us. When we both left, we were thanked and everything, but not to the extent of our male colleagues. Which was fine. We never got the same recognition as our male colleagues. Again, we know what we did, so we don't need it. But it was never allowed to escalate to be a problem. But it is--this gender difference is something that we all noticed.

Q: Absolutely. I'm interested in--it sounds like during your time, you were really conscious of shared traumatic histories in Sierra Leone. The fact that you said many of your local staff had been child soldiers. How did these stories get told?

GHISELLI: No one ever told me directly a story. This is more something within 01:45:00the teams going to the field. They're in the same team every day, so after some weeks of working together, local staff might mention a sister or a spouse or a parent to one of my WHO colleagues, and then they would tell me. Not for gossip, not for information, just like, "Have you heard about this horrible thing? And he's still standing and smiling. I would be devastated, even ten years afterwards." It's the kind of thing that you learn about a person just by working with them in the field day in and day out. It's the same thing as with the witchcraft. At some point, you start talking about these things. But it was just very striking to realize how many of our colleagues had been child soldiers. It explained so much about their attitude and relationships in the villages, and how villages receive foreigners or strangers. Nothing good ever 01:46:00came of it. So it just put it in context, how much more difficult the response was going to be in Sierra Leone because of that history.

Q: I typically like to sit back and just listen to people give narratives and feel guilty asking questions. But I want to ask at least one more about Kambia. And that's--you're there on--seconded to WHO. You're with WHO, kind of outside CDC. What is it like looking at CDC from the outside?

GHISELLI: When there was one at a time, it was quite nice. When you start getting a group of three or four, it becomes a little bit more complicated. CDC and WHO see themselves as public health agencies. And from a purely WHO 01:47:00perspective, I think CDC doesn't like to share. On the other hand, WHO is very certain that it is the first and foremost partner of the Ministry of Health. There is no space next to number one. We run this response and you support us. Sometimes things go really well, and sometimes other people have different agendas or want to run things differently. Because we are occupying the same niche, it becomes difficult. CDC is certainly more technically competent than WHO just because of the quality of people it sends over. WHO finds consultants among its staffers, its consultants, its GOARN volunteers, pretty much from all over. Even if you're a WHO staffer, you don't necessarily have the highest education level, certainly not compared to someone who's been fully educated in 01:48:00the States. On the other hand, WHO brings an immense wealth of local knowledge, and just knowing how to work in Africa, which is not something that you pick up by reading a book. So especially for me, I felt 100% WHO in this response. CDC was something for which I would be happy to do anything that I could. But I'm WHO here. So we set the agenda, and we work to integrate you into the agenda. With some people more than others it was difficult to get this concept [through]. But in the end, I think we managed to form strong teams. The CDC staffers were field epidemiologists exactly like the WHO ones, so they were used interchangeably in teams. It's not like there was a CDC role and WHO role. We 01:49:00were all field epidemiologists. You were assigned to different teams and this is where you go. Because English was the common language, no one had any language barriers. Anyone could fill any role. So by the end it was quite well integrated. But I think that sometimes it was difficult to accept that WHO was number one.

Q: I know it's probably an uncomfortable area, but I'm wondering if you can go into a little more specifics. You don't have to name names or anything like that, but--I know that you had personal experiences with this.

GHISELLI: Yes. But--so, for example, one area when we did this "assault," someone from CDC said this was a terrible idea. That it was just investing too many resources in too many different places, we needed to be much more targeted. And our point was, well, we know this is a problem area, because we don't know anything about it. So we just want to go in and see what we find and cast a net as widely as possible. That created a bit of a conflict. And then--I'm sure 01:50:00you've heard a lot. CDC turnaround was a huge drag on us. Sometimes people would come for two, three weeks. I can't spend that much time training someone for two, three weeks. You want to start your own project, fine. But don't expect me to fully support you. I don't have the time to do it. You want to do interviews? Yes, go, I'll organize the initial introductions for you if you want. But otherwise you're on your own. There was no time or space for individual projects. There was no time or space for trying out different strategies. Unfortunately, we had to think of one and go with it and adjust as we went along. This is things that we had decided beforehand, we got approval from the DMO and DC, and this is where we're going. So we didn't have much time for parallel projects or alternative strategies.

Q: I know you mentioned it was different interacting with CDC people 01:51:00individually, versus when they're kind of clustered.

GHISELLI: Right. Again, it depends on who's forming the--the individuals forming the clusters. When it's one person at a time, it's very easy to pull in that person in meetings or in side chats, and then CDC is informed. But when you start having three or four people, and no one is the official team lead, then I don't know who to inform. Again, all these meetings are happening on the fly during the day when everyone else is outside doing fieldwork. I can't wait to have the meeting and for someone from CDC to come in. If there had been a CDC team lead, it would have made sense to pull that person in in all the meetings. But on the other hand, with a group of four or five, I don't know if you actually needed a team lead for Kambia. So in that sense, when the group is 01:52:00small, you can just pull people in and consider CDC informed. When there is a larger group, it becomes a little bit more difficult.

Q: I'm remembering when you were talking about cc'ing, the importance of who is included in emails back in AFRO work.

GHISELLI: Yes. Here I think for--when CDC needs to know, I would have copied everyone. Which is fine. But then I would treat them more as field epidemiologists versus a one-on-one relationship with a partner. I would consider them as part of my field epidemiologists to be deployed. So as part of my team.

Q: So how did things wrap up? You know what, I should've--I asked that too soon. I had one more question.

GHISELLI: We still have Guinea, though.

Q: I'm so sorry. I know we have Guinea. And we're going to get there. Partners In Health, Port Loko exposures--you know, while you're there, March--did you 01:53:00have any experience hearing about that? Did it affect you at all?

GHISELLI: No. We heard about it, and we thought that, for once, Kambia was the stable district. [laughter] Look at that. We're the calm and collected ones for once. No, it was crazy also because the previous WHO field coordinator for Port Loko, Boris Pavlin, he was staying in Kambia with us for a couple weeks, just giving his inputs in Kambia. So he had to rush back to Port Loko and try to--to calm things down and try to get a little bit of order in a sense because the new field coordinator wasn't quite there yet, in terms of leadership and experience. And Boris is very good. He's WHO staff in Papua New Guinea, still there. But he was there in Port Loko for three months as well. He's very, very, very good, 01:54:00very solid. That's why he was in Kambia trying to help us out for a little bit. But he had to rush back to Port Loko, and just trying to calm the chaos. Because he had relationships with everyone. He was very well respected. And trying to get a little bit of a sense of order. It was like, okay, so DMO do this, and this is the message. DC, you stay here. The British contingency, this is what we need to do. But we were all watching from the outside and marveling that, for once, we were not the problem child.

Q: Okay. Sorry, back to the main track. How do things wrap up?

GHISELLI: My replacement arrived. He was the director of the Department of Health for Perth in Australia. Good guy. He spent a week shadowing me and then a week being team lead while I was in the shadows. He was going to stay for a 01:55:00month after I'd left. I think he wrapped up quite well, but it was--I had not realized what a wealth of information we had been able to accumulate and construct. So the handing over was quite onerous. It was a lot of side chats and discussions and sharing of documents and explaining what the relationship is with this person, who do you want to piss off and who do you not want to piss off, and who do you need to respect, who do you need to copy on emails every time, and where--what is our final vision for this project? We want to increase the number of contact tracers. How do we do that? Who pays for them? How do we negotiate in a context where the government wants to start withdrawing contact tracers? So what kind of arguments do we put forth? All of these kinds of things. It was a very intense two weeks for him. Then I hand it over and left. I 01:56:00had a very, very, very nice farewell party. Lots of dancing. No, it was great. It was a really, really, really good sendoff. And the next day, obviously I was very sorry to leave. But three months had been a long time. I had already extended twice with my office in Gabon. They were not happy because they had settled for one month, it became three. Again, there was just work to be done in polio as well. So I wrapped up and then went back to Gabon for three weeks before going to the States for a week.

Q: Gotcha.

GHISELLI: Yeah, so that's how it wrapped up.

Q: So in the States, is that vacation time for you?

GHISELLI: Yeah.

Q: Good.

GHISELLI: Yes, yes.

Q: More or less?

GHISELLI: More--no, I'm trying to think. It was the first time I was back--I was outside of Africa in the last fourteen months. So it was a much-needed break, 01:57:00especially after the three months in Sierra Leone. It was just like [sighs]. I need a break. I need to be on my mother's couch. I need to be eating and thinking of nothing else. So yeah. And then I went back to Gabon.

So, I come back to Gabon, and not in the best of moods. Because I've experienced Ebola. The adrenaline rush of every day, having a full, full calendar every single day, seven days a week, and it never stops, and it just keeps going and going and going and it's very high-adrenaline, it's a stressful environment. You're doing meaningful work. You see the results immediately, or not. But if you don't see them you know you did wrong. So you go back and fix it. You're interacting with fifty different people a day. And then you come back to Gabon, and it's polio work. And it's like, do this report this week. When I was used to 01:58:00typing it up in an hour and a half, same length, same quality. Or, "What do we have to do today?" "Well, we need to do the conference call." "Nothing else?" So the change of pace was very, very difficult. And I was hearing back from my friends from Sierra Leone, and they were all having the same problem. Just boredom and--you're still ramped up, the adrenaline is still high. And no one gets what you've been through. No one is giving you the recognition you think you deserve for having done so much in such a leadership position in such a stressful time. And you know they appreciate it. Well, not in--no, actually no. They don't appreciate it, because that's another thing that all my colleagues and I--WHO colleagues and I have in common. Everyone is pissed at us because we took so long to come back. I have a friend who was in the Manila regional office 01:59:00for WPRO [Western Pacific Regional Office]. His boss is pissed that he took three months off, like really upset. This friend of mine, Boris from Papua New Guinea, as well. "I know you're having fun in Sierra Leone, but you need to come back." My office is that kind of passive-aggressive silence of, "Do what you want" kind of thing. I had another colleague whom I met briefly in Guinea. She was from the Haiti office, and it was like, "They really want me to go back, but I'm needed here." So all of us WHO staffers, those of us who actually wanted to be there and stay there for a long time, we all come back to very grumpy colleagues. There's that sense that I have been begrudgingly forgiven, and I have come back. The sense that I'm still ramped up and there's not much to do. So I'm not there with the happiest of spirits. And then two weeks in, I get a phone call saying, "You want to go to Guinea?" "Yes!" [laughs]

Bruce Aylward, who was the leader of the WHO response, he was in Kambia several times, to the point that I go from not having any idea who he is to "You again." He's a nice guy and everything. But his visits are always a bit stressful, and you have to prepare for them. When I left Sierra Leone, I sent him a message saying, "Hey, I'm leaving, thank you very much." And he's like, "Well, keep in mind for volunteering again." I was like, "Sure, just let me know when." So when I come back to Gabon, after a couple of weeks, I get a message saying, "You've been selected to go to Guinea." I was like, "Yes! Yes!" So I try to keep a straight face in my office saying, "I'm being deployed to Guinea. There's nothing I can do." Again, WHO-AFRO, this is a deployment. There's nothing you can do. You want to push back, maybe, but you don't refuse. I have to go to 02:01:00Guinea. And this time it was very clear that it was not only because I did well in Sierra Leone, but because of the French as well. Because I had been sent to Sierra Leone coming from a Francophone office, I had been sent to Sierra Leone as the one Anglophone that they had on hand. So I got sent to the Anglophone country. But now Guinea has a great need for Francophones. And in my office, everyone has already done one or two rotations. So they're kind of maxed out, that they've done--well, not everyone. There's a lot of people who didn't go. But those who were eligible to go went. But only for the required month, no more. So they need people. And they say, what we're thinking for you was liaison officer for cross-border relationships in Forecariah. I was like, I've been to Forecariah before a couple of times. Sure, I'll go. Not that I have a choice, 02:02:00but I'd be thrilled to go. I didn't word it that way, but that was the meaning. I did not put up a fight.

And I arrive in Conakry, and also, I'm interested in seeing how different the system is in Guinea compared to Sierra Leone. Same disease, different way of doing things. So I arrive in the Conakry country office for WHO, and the first thing we do is a training. The person giving the training is the surveillance focal point, Dr. Diallo--what's his name, oh my gosh--Boubacar. Dr. Boubacar Diallo. Dr. Boubacar Diallo who is, at this point, so famous. He has very specific gestures and ways of saying. He's quite a character, but also the guy who stuck with Guinea for a very long time, so he deserves all the accolades. 02:03:00But he's also very--has very characteristic gestures and phrases. But a very good guy. He's doing this training, and he knows I've been to Sierra Leone, so he keeps pointing out the different things in between Sierra Leone and Guinea. How what we call a probable case in Sierra Leone is someone who has--who most likely has the disease. A probable case in Guinea is someone who has died, and you haven't had a chance to test that person, but you think he or she might be an Ebola case. But that person is already buried, so there's no way of doing a test. These kinds of things. It's like, same words but completely different meanings. How information is reported back. Sierra Leone, the districts have almost complete autonomy. In Guinea, like in any Francophone country, everything is very centralized towards Conakry. So you always have to wait for authorization from Conakry, be that WHO or the government or any other partner. 02:04:00So things are very intense--are very focused on Conakry. But it's agreed that I go to Forecariah. After a very bad road--it's only one hundred kilometers but it's a very bad road, and very heavy traffic--I get to Forecariah. And people already know me, because they'd seen me on the Sierra Leonean side. I arrive and they're quite pleased that I'm there. They know me, and they see I speak French, so it's not going to be a problem, which it oftentimes is, but it's not going to be a problem, so that's good.

A couple of things strike me immediately as different. I mentioned in Sierra Leone, being an Anglophone country, you could bring in consultants from everywhere. In Guinea, there is no one. There's the Guineans. There are fellows from the FETP program, the Field [Epidemiology] Training Program from DRC, from 02:05:00DR Congo. There's the French Red Cross to run the ETU. And that's it. These are the people who came and helped Guinea. So not nearly as many partners. Not nearly as well supported. Sierra Leone had the British military, Liberia had the Americans. The French did not come for Guinea. The relationship between Guinea and France is very strained since 1958, when Guinea wanted to be independent, despite what [President] Charles de Gaulle was saying. They got their independence and got completely cut off from France. The relationships have been strained since then. The French military did not come for Guinea. Just French Red Cross came, and it was a very small contingency. MSF is there, Doctors Without Borders/Medecins Sans Frontieres, they're there. They're doing what they can. They're running the big ETU out of Conakry. But all in all, it's the 02:06:00Guineans. While in Sierra Leone, the Leoneans did not have that prominent a role, the Guineans with the same type of background and training, they have to take on leadership positions because no one else is coming. I think they did an amazing job with such few resources, such fewer resources than the other two countries, such limited support compared to the other two countries. They were slightly behind the other two countries, but they did an amazing job.

Everyone--I remember hearing a lot, in Sierra Leone and Liberia, people saying, "In Guinea you don't do anything. They're not capable. You're not doing anything. You don't want to." And then you move to the Guinean side, you know that they're doing amazing work. It's just because the documents are not translated into English that you don't know about it. You don't read the sitreps. You don't read the memorandum--the strategy documents. You're not fully 02:07:00aware of everything that's happened. Communications cross-border are difficult because the languages are different. But Guinea is doing an amazing job by itself with a little bit of support. I have worked very closely these three months. I arrived in June and left in August, August 14th. I have worked very closely with the Guinean physicians who were our field epidemiologists. You could not ask for more. You just--you just can't. They spent the nights in villages so that they could do contact tracing early in the morning. Like, for forty days. We've been in these tents. It's like living like a refugee. And these are trained physicians. These people come from very well-educated families. They are not--this is not what they're used to. They do not want to live in a village with all the issues with food and washing and no electricity, of course. And they did it, and they did it without complaining. You cannot ask 02:08:00for more. They did it--I mean, the field--I was not field coordinator there, even though I often took on the role because the person [Dr. Amadou Mouctar Diallo] was away. But the field coordinator kept saying, "You are patriots." And it's true. I mean, in the purest sense of the word, you are patriots. Because you're doing this for free, for a very limited stipend, which barely counts. You're doing it for your country. It's more than you could ever ask anyone. Certainly more than any of us have ever done for our countries.

So Guinea was a completely different experience, but a very, very good one, equally as valid as Sierra Leone. I think here in Guinea, I was much more involved in fieldwork. Then I really got to work in the villages in--with the Guinean colleagues, and see much more closely what my colleagues in Sierra Leone 02:09:00were talking about when they spoke about hesitancy in the community, or just blatant lies, or hiding bodies, or things like that. I'll just finish, before I launch into a very specific example, but because partners were fewer, there were just fewer partners, there was not that much work to be done in the office. We had Doctors Without Borders. We had French Red Cross, who was reviled. Everyone hated them. The rumor was that they were not providing the best care, so that a lot of people went there to die. Now, there are a lot of reasons why people reach the ETU and die. They might have been notified too late, or they--I think that being the French Red Cross, the standard of care must have been pretty high. But there was also a problem with attitude, which--it was clear that the Red Cross French volunteers were not as willing to be part of the community as 02:10:00other partners like Doctors Without Borders. So there were a lot of issues here. People wanted to be taken to Conakry and spend hours in a truck, rather to be taken to Forecariah, to the ETU in Forecariah. So we had to fight that a lot.

But basically, because there was not that much activity in the office, I was free to be more in the field. We also had a very, very good prefect--not the prefect, the prefectural officer [Forecariah Prefectural Response Coordinator Dr. A. Batchily]. The equivalent of a DC in Sierra Leone. His equivalent to the prefectural officer in--or the prefectural coordinator in Forecariah was very active. Now him, the WHO field coordinator, and the majority of the WHO field 02:11:00officers had been in Gueckedou. Gueckedou. There was the prefecture where the outbreak started. This was the first team sent out to investigate what was happening. And they did a very good job. That's why they were all sent in block to Forecariah, to repeat the same job here, to maintain the same dynamics. These poor guys who are from the Forest Region, they are now in Guinee Maritime, in the maritime area. Far from home, far from their families, making it work. But they were the team that was brought in block because they were so good. The same team was sent to Nzerekore, also in the Forest Region, for these last ten cases. It's the same block of people. So our big, big exploit when we were there in 02:12:00Guinea was--well, two things. One was creating strong relationships with Kambia. The cross-border surveillance system we set up was based on very simple things. Like, despite what we believe of each other, we are both sides very competent at what we do. We can trust each other. There's no need to create joint teams, or to go into each other's territory and follow up investigations, no. We just need a very strong chain of communication.

Q: Had there been an issue with thinking that?

GHISELLI: That's one thing that the DC in Kambia thought that we needed to do. That Kambia needed to save Forecariah. And we kept saying, no no, we don't have the resources to save ourselves, let alone Forecariah. Fortunately that never went further because we didn't have the resources. When I was there, my biggest issue was, one, translate all the documents in both languages so that we can understand each other. Have bilingual liaison officers, myself and someone else in Kambia to exchange information with anyone on the other side so that language 02:13:00would not be a barrier. Then, every time we had a suspect case moving or a confirmed case from the other country come into our country, we would immediately inform, and a team from that side would go investigate. So we would investigate suspect cases in Kambia because now they were in Forecariah. And we would send back the information immediately. This happened ad hoc, so multiple times per day. There was not a set time. We held bimonthly meetings in one side or the other. They were not particularly successful because we--the work was more of the exchange of information, rather than--we each know what we're doing. We don't really need to come together and discuss how we're going to do it. We're already doing it. So not very successful in that sense, but we kept having them just so we knew each other's faces, and that makes communications easier. We would be patrolling villages along the border so that we would be the first 02:14:00ones to hear a rumor and pass it on to the other side as well. We had our key informants on both sides, in villages on both sides, so that they would be able to tell us where this person had gone. So if I hear the name of a village in Kambia, I'm able to immediately call someone in Kambia, and they on a map can find out where that village is, and that's where the team is going the next day to investigate, asking specific names and places and dates. We got a lot of information that way. We also used the MOU to decide, if you have a suspect case, where does that person go? Are we crossing borders again to take them to the ETU where they belong? Or are they staying in the ETU on the side where they were found? Is a Sierra Leonean ambulance really going to take charge of a Guinean person? Yes, because Guinea is doing the same thing. So all these things.

We worked through a lot of these details. But the bones of it was constantly 02:15:00shared communications. I think that worked, because when we had a meeting in Sierra Leone of all the districts to talk about cross-border surveillance, we were invited as well. I think--no, I know Forecariah and Kambia had the strongest cross-border program by far. We had started thinking about it in February, and by July, August, it was very strong and very well operating. We knew immediately we would be able to draw maps of both district and prefecture. They were always presented together. We knew exactly what kind of villages were on the other side, and where the cases were coming from, where they were going. To the point where we also knew about all the affairs and all the relationships that people were having across the border. We knew a lot of details from people moving back and forth. Because there were three official crossing points, but really like fifty-three unofficial crossing points that we knew. And surely much more.

Q: So for example, if you get word that someone has gone missing or crossed over--I don't know what you hear--do you kind of know who their contacts are, their family are on this side of the border, and just check with them? Or what do you do?

GHISELLI: So we have--for example, we have a known contact who escapes at night from a village in Sierra Leone. The next day, he's not there to be counted. So we sit the family down, and we do not let them go until they tell us everything they know. Obviously, no coercion. But we insist very much with the social mobilizers, we ask other family members, we reach out--we try to find some details. Then the liaison officer, or someone in the field, calls me. Everyone knows me, and everyone knows the other liaison officers. Someone calls me or emails me saying, this is the information we have with this person, age, gender, 02:17:00where they're coming from, where they're going, when they left. And this is the village where we think they are. That's where we send a team and try to obtain as much information as possible. Different names, maybe the person used a different name, different family names. We try to triangulate the information so that we can at least identify where the person has gone and who are his contacts, and then continue from there. Usually we are quite successful. Also because at that point people have heard that a possible Ebola case has come from Sierra Leone. No one wants to keep that person in your house, because you may not believe there is Ebola in your village, but from a foreign country, absolutely you believe that they have Ebola. Absolutely you believe that. So in that sense as well. We got a lot of--we got more support identifying people from Sierra Leone. It was the same thing in Kambia as well.

Q: Okay. I'm asking questions again, I apologize for that. But were there ever instances where you had to tread the line, because someone might feel 02:18:00criminalized by this kind of surveillance?

GHISELLI: No more than they would already be, in terms of following the contacts. If someone goes missing, we follow them. We follow them as much as we can. We cannot afford to let them go. Towards the end of my stay in Forecariah--it's true in both Forecariah and Kambia that the cases--the new cases that are springing up are due to contacts lost to follow-up. That is our main problem right now, and the one source of infection that we have left. So we are not leaving anything to chance. Yes, many times we felt like we were being the police. We actually had to restrain the local authorities sometimes who just wanted to throw people in jail. It was like, no. But yes, we did follow them quite doggedly. We just couldn't afford to leave anything to chance. It led to 02:19:00some unfortunate situations where people really did feel like they were on the run. You try to do everything you can with social mobilization, try to explain what's happening. But a lot of times you identify the person and you evacuate them right away. But, yes, you do feel like the police.

Q: Gotcha. In those situations, where someone did feel--you know, like I'm on the run, etcetera. Were you ever in communication with that person?

GHISELLI: We were in communications with their--

Q: You personally, I mean?

GHISELLI: No.

Q: Okay, gotcha. I know you said you did more kind of fieldwork type stuff in--

GHISELLI: In Guinea--

Q: In Guinea, so that's why I was asking.

GHISELLI: In Guinea we never--in Guinea it was complicated, because--I mean, everywhere was complicated, but I learned about it for real in Guinea. We had relationships with the family members, with the neighbors; but with the person itself, it usually was through a second source, an intermediate source. Then we 02:20:00would finally find the person and immediately evacuate them. So we would not--in some instances other people, social mobilizers would have negotiation sessions with that person to convince them to be evacuated. But I only saw one case. And because the communication needed to happen in the local language, obviously I was not involved. In fieldwork the idea is that I would try to keep out of sight as much as possible. Again, because I am so visible and conspicuous. We don't want to add another element of distraction and concern to this whole situation. I only saw one instance where the person was being negotiated to be evacuated and the person was refusing. They finally managed, but no, usually we worked through intermediaries.

Q: Gotcha. Thank you. Sorry to interrupt the--

GHISELLI: No, no, no.

Q: --the kind of flow of the chronology here. So how do things--how do you see things changing? How does your work change over the course of your time in Guinea?

GHISELLI: At the beginning I'm taking on the same type of work that I did in Sierra Leone, because that was what felt more natural. Now, of course, there's another field coordinator, so I'm very careful not to overstep or anything. Also because it's a new system. There are a lot of things I don't know. Lots of new terminology to learn, different acronyms. Obviously it's a different language. Nothing completely new, but it--in translation. At the beginning I'm moving carefully, I'm trying to understand, trying--I'm having meetings with other partners to explain to me the situation a little bit. And trying to make myself useful in any way I can. The field coordinator has just had a baby in Conakry, so he's back and forth quite a bit. Unofficially, I'm the field coordinator when he's away. But I'm not seeing that my presence is absolutely critical in the 02:22:00office. So I start going out with the teams a little bit more. That's when we hit on Benty, on the sub-prefecture of Benty. And that is a long story.

Benty was the sub-prefecture right in front of Samu Chiefdom [in Sierra Leone]. Right on the coast, right against the border with Sierra Leone. It is an area where nothing--no cases had been reported for about one hundred days. It's quiet. Nothing is happening. We just have one epidemiologist go down there once in a while and check on things. MSF picks up on a rumor of someone has died. It has not been reported. Who is this person? What do we know of her? Well, she 02:23:00attended her brother's funeral in a totally different part of Forecariah, which does have active case transmission. Then she came back on a motorcycle with her brother. Then, rumor has it that she got sick and died. Well then. And then we start hearing rumors of the brother being dead, a wife that might be a sister, and children who might be nephews or children, also not quite sure, being left at other villages. It gets to a point where we have six potential cases. We can't call them probable yet, because they're not linked to any confirmed case. We just have rumors of deaths and no one knows anything. The aunts and uncles to whom supposedly these people have come have never seen them, barely know who 02:24:00they are. "But we know that he came to you Tuesday night!" "Nope, I don't know who this person is." "But you're the uncle." "I don't know who this person is." Okay.

Basically, in the end, we finally identify a woman and a child who are sick and go to the ETU. The woman dies, and the child is finally tested and confirmed to be a case. She is one of the daughters of the brother [of the first woman who died]. So finally the other six cases become probable cases officially. And that's when we start seeing this thing just balloon. We're just seeing every village--it's amazing, because so--Benty is a province, it's quite long and not very wide. There's one road that goes through it, like in a serpentine. And all these villages along the road. You can just see cases springing up as the brother picked up his three wives and children, just start walking in the night. You can imagine them. Then as the wives and children get sick, he drops them off 02:25:00at relatives' houses along the road, and he continues until he gets to the end of the peninsula. And he is so sick that he actually tries to hang himself. This is his uncle telling us this. He actually shows us where he finally died and was buried, along with his other wife who actually made it with him. But then we start going back along the road, and we find all these--first wife, second wife, third wife, and all their children. And who died here, and this child was taken to the grandfather's house which is way in the middle of the bush. That child we never found. Could be dead, could be fine, or could be hidden in another house and called another name for now for all we know. We meet with one of his wives who actually managed to survive and now she's back home. We bring her rice and other foods because it's clear that she's not well, she needs to recuperate. By 02:26:00the end, we have seven or eight villages that are implicated, and we have to put all of them under quarantine. It's just amazing how it just spreads. We start with probable cases, then we start with confirmed cases who then died, then we start with confirmed cases who we were able to evacuate, and then we start seeing survivors, and then we finally start seeing contacts who are not affected. Within seven weeks, we saw the whole progression up until the end of the twenty-one-day period.

I did a graph, I'll describe it a little bit. Basically it has the whole transmission chain on it, because it needed to be documented. But these are all the confirmed cases of this Benty chain. You start with the orange dots, of which there are one, two, three, four, five, six, which are the probable cases. 02:27:00These are the people who died before we were able to test them. But we know they have an epidemiological link with the cases. The cases are in red.

Q: Gotcha. This is like a family-tree-style diagram where there are colored circles--layers of colored circles, rows of them.

GHISELLI: Mm-hmm. And for each row, you see that's a new wave of infection. So you can see the different generations of transmission. And the red dots are the infected people. The ones with the black numbers are the ones who died. The ones with the white numbers are the ones who survived. And then you have starting the suspect cases in yellow. These are the ones who we thought were infected, but it turned out they were negatives. And then you have these green dots with the red circle around them. That means they were suspected cases who ran away and we never were able to find them. We have no information on them, but there are four of them. Of whom--and some of them, we were told they went into Sierra Leone. We 02:28:00tried to follow the rumors, we couldn't. They went somewhere else. But as you can see, we're talking about--I think we get to thirty-eight. So thirty-eight people in this family tree. You can just see the progression with the orange being the probable cases, and then go to the reds, which are the confirmed cases, and then the yellow, which are the contacts who are not infected. This is the kind of work that we did generation after generation. Living in the villages ourselves, evacuating people at the first sign of disease. Just like a little bit of fever, you're out, because you're a very high-risk case. Just being able to follow these people, house to house, every single day twice a day, very closely, and being able to evacuate them immediately.

Benty was particularly difficult because it's a very remote area. It takes about 02:29:00two hours to get there from Forecariah. And we had to do this every day. Now, the local staff could stay there in the villages and sleep there and do contact tracing, which was very tough for them. But for us, we had to travel that road every day and be there with them every day. So we were their link with Forecariah. We brought them news, we brought them soda. We helped them--if they had some questions, we did a kind of an analysis of the situation every day. We identified what the issues were, what are the different chains of investigation that we want to consider. We want to know exactly what the next steps are for each person. Because at this point, we know every single person in these seven or eight villages. And these villages sometimes--it's so easy to cross into Sierra Leone. So easy. People just come and go. And another big thing about Guinea is that people are not quarantined in their houses. They are free to come 02:30:00and go as they please, as long as they are there in the morning and the evening to be followed. The idea is that if you're not symptomatic, you're not infectious. Which has worked surprisingly well, contrary to what people in Sierra Leone were saying. It has worked surprisingly well. But it also makes our task a little bit more difficult because we need to ensure that people are back in the evening, that people go to the field but actually do come back home. There was a time when we were in Benty and we were pushing so much, asking so many questions, that people started really getting upset with us. It was like, what are you doing? Not only do we have dead people now, not only do we have sick people now, but you keep asking questions, and very invasive questions. So there were a couple of times where the situation got tense. One time there were 02:31:00people from a village throwing rocks and blocking the road. The prefectural guard had to be sent in with the prefect. Not to do anything, but just to clear the road. That was a tense morning on the phone with my teams, trying to bring them back, and just making sure that we knew where each person was in each vehicle, and that everyone was fine. Situations got a little bit tense a couple of times.

But I think that we had two things going for us. One, we were working very closely with MSF, which is not an obvious thing. It takes a lot of work to work very well with MSF, especially [if you are] WHO. But we did it, and it worked really well. They were in charge of evacuation with the ambulances, and they also had the relationships with the key informants. So they are the ones who catch the rumors. Then we share information and we were able to do very well 02:32:00together. The second thing we had to go for us was that despite being very long, Benty is a pretty--very closed system. All the villages are along that road. Once you have that road well-mapped-out, you have Benty well-mapped-out. By the end we were all experts in Benty, in Benty geography. We also knew exactly where each village was, and who was living there, and what kind of information we would get out of them. So it was also a very discreet environment. I think the one thing that set us off on the right foot for this investigation was also that at the beginning, we would sit down, WHO and MSF, all the field epidemiologists who had been out that day, and we would review every single piece of information. And we would sit there until we came up with a coherent story. Working through the different pieces, asking questions of one another, trying to 02:33:00get information, elucidating each piece, so every day everyone went out with the same coherent story in their head. That helped a lot to just make sure we were all moving from the same block.

Then pretty soon in this investigation I started putting together a report, a field report of the investigation that I would update each day, make a coherent story, and share it with everyone so that everyone knew what we were working on. So if Conakry had a question, or Geneva had a question, we could just pull out the diagram and say, this is where we are as of yesterday, or of today, depending on the hour. That really helped keep a coherent story because this thing was exploding and we had to keep it structured. There was a lot of post-mortem analysis after the investigations that happened in the field. It was a lot of analysis that happened afterwards in the office, and I think that made 02:34:00a huge difference.

Then moving into the villages [for cerclage], which was very uncomfortable for our team members, but it helped immensely with relationships with the villages. Because people who are willing to live with you and follow you and allow you to do your work, by the end they were playing soccer together. They had a very big party when quarantine was lifted, and we were invited. They had jugglers. It was very good. And acrobats, too.

Q: Wow. That sounds great.

GHISELLI: It's very good, yeah. But that was the biggest thing that happened in my time in Guinea. And it was so completely different from what I had experienced in Kambia. Very, very different roles, but both equally significant I like to think.

Q: What was the span of time that you were working on the Benty cluster?

GHISELLI: Seven weeks. Seven weeks, yeah. Because from the first rumor up until the end of the twenty-one-day quarantine.

Q: So this quarantine--or do they call it cerclage?

GHISELLI: Cerclage is something different.

Q: Oh, it's something different?

GHISELLI: So quarantine is what you usually do when you have contacts of a case. The usual follow-up every day. Cerclage is something that we first experimented in another village in Forecariah, but then we implemented full force in Benty, which is where the field epidemiologists stay in the village. The village is cordoned off and people cannot leave except to go to the fields to work, which is all that they wanted anyway. It's a closed--becomes a closed system. People are not allowed to travel outside of their fields. And field epidemiologists live there with them and follow them in the morning before they go to the fields, so at 6:00, and in the evening when they come back. So cerclage is something that I think was done very frequently towards the end. But it started 02:36:00in Forecariah, and Benty is when it really came to full fruition because they had a little tent city there, even though we were bringing them lots of food.

Q: Can you talk about that? Bringing in the resources, and what partnerships you had to form with that?

GHISELLI: So people who were there were UNICEF. But they were coming in and out every day. They were not sleeping there. Only WHO was sleeping there. And the military guards who were there just to cordon off the village, but in reality they didn't have much to do. WHO was the only one who was really sleeping there [note from M. Ghiselli, December 2016: incorrect, military were sleeping there too]. Everyone else was coming in and out. For WHO, poor guys, they--there are like thirteen in a tent. It was a big tent, but--men and women mixed up, and you can imagine in a Muslim country. Finally they pulled up a partition on the women's side, but it was rough for everyone. Also because the men expected the women to wash their clothes, to which they said absolutely not. And to cook 02:37:00their food, to which they said absolutely not. The women would cook their [own] food and wash their [own] clothes. So I think the men had it worse because they didn't know how to do any of these things. One of them in turn would go back to Forecariah each evening and bring back dinner. Because there was really nothing to buy in the village. Maybe you could slaughter a goat, which they knew how to do. But it's not something you can do every evening. I think that they were--they were very good about it, but I'm sure that it was difficult. Also because in the evening, of course, no electricity. They had to have flashlights. And they have to send in a report every day. So they're with their hotspots trying to catch signals, and sometimes waiting until the middle of the night to be able to send their reports.

One thing that we did do, we [other CDC staffers and I] tried to ease their burden as much as possible, so whenever we went in we would bring them boxes of soda, cans of soda. And maybe some food, you know, candy bars or something like 02:38:00that. If they needed anything from the office we would bring it to them. Their reports we would bring in--we would bring it in verbally [to the office in Forecariah], and then they would be a little bit more relaxed to send it in later in the evening. But at least the official numbers would be in by the time of the evening meeting, and we would bring them in. We just tried to be as present as possible without actually living in the village. And that, incidentally, is something that does come in handy when CDC asks what we can do. Because CDC staffers are not allowed to stay in the villages. I always say, well, as a white woman neither could I. But I made myself useful as much as I could. I brought them snacks, I brought them drinks, I brought them paper when they needed it. I did the analysis of the situation with them, and I was there every single day. I think that that more than anything has made a difference, 02:39:00just to be there and to be sure that they were well taken care of, and they could actually see a physical person be there with them every single day. I think that made a huge difference, and therefore it never really mattered that I was not there with them. I was fully part of the team. That makes a huge difference, especially when you're the one writing the report in the evening.

Q: Were you also providing resources to the community at large?

GHISELLI: No, that was more a UNICEF role. But resources to the community--well, no, that's not true. At the end of Ramadan, the local government, the prefecture brought in two bulls to be slaughtered. It was a quite a handsome gift. Everyone recognized it. The villagers were incredibly happy. Lots of protein. No, they brought in--UNICEF brought in generators, of course. For the tents, but also for the villages. There was healthcare services, free healthcare services, so that 02:40:00if you had anything that did not look like Ebola, you could get free treatment right then and there. That was in the middle of the villages, so anyone could come and get your anti-malarials and whatever else. It was also a way of--you don't feel well? Come and we will evacuate you. So it was also an incentive. I remember this one case, a very, very malnourished little girl, a baby. We worked with UNICEF the whole afternoon and managed to evacuate her to Conakry where UNICEF had its intense feeding programs. That's the other thing, once you start seeing fewer cases of Ebola, but you're still in the villages, you start seeing everything else. You're not equipped to treat or even evacuate anything else. So you have malnutrition. You have cases of albino women with [obvious] skin lesions. And there's very little you can do. What we did was to call the 02:41:00non-Ebola ambulance and take them to the hospital. But even that, it's fraught with complication because who's going to pay for this? We often chipped in to pay for whatever thing the person needed. A night at the hospital, food, a specific medicine--

Q: When you say "we," you mean you personally?

GHISELLI: Me personally and the Guinean field epidemiologists. So those who came with me every day and those who stayed in the village. We often collected money, and we just did something for this person. But it's a one-off. For example, I remember one time we had one survivor. Him and his whole family pull through. We were just so happy. Then one of our physicians, field epidemiologists, started saying, "He doesn't look good. He doesn't look good. I think it's renal failure." It was like, what do we do about that? So we managed to get him evacuated to the [Forecariah] hospital in a non-Ebola ambulance, because he's a 02:42:00survivor, so it's not an Ebola situation. We take him to the hospital. Then we have a huge fight with the laboratory people who have not been informed, and therefore will not draw blood on this person. It's like, this is an Ebola survivor. What do you mean you're not going to [draw] blood? We finally manage, but it took the whole afternoon and it was quite intense. Fortunately the person turned out to have nothing specific, so he went home. But the question was, okay, so we brought him to the hospital. We gave him his diagnosis. If it were positive, what were we going to do? We can't pay for his full course of treatment. We're not going to be here for that. Also, what happens? I was happy to see when I came back to Guinea now in April 2016, there was a lot of attention on survivor care. Because at the time when I was there in August, there was none. It was just, you don't have Ebola, therefore right now you are 02:43:00not the issue. I even had someone in the village come up to me and saying, "What are you doing about malaria?" I was like, "I have nothing to give at this moment for malaria." Even though I know it's killing more people than Ebola. My ambulances are for Ebola patients, and all my work is on Ebola, and that's the emergency right now. But I understand that all the sequelae of Ebola aside, malaria is a huge concern. Diarrheal diseases, huge concern. What do we do about that? These are regular people, not even survivors. So Forecariah was a very different experience than Kambia, but also quite intense.

Q: So does your work in Benty kind of wrap up your experience--your first experience in Guinea? Or what happened--

GHISELLI: So, the wrap-up--I had maybe another week, and there was another smaller outbreak right outside of Forecariah that I had started to follow, but I 02:44:00had to leave afterwards. Because again, my colleagues in Gabon were grumbling pretty strongly that I had been away two and a half months now. It's just like, do you want to change jobs? It's like, well, not yet. But there was that smaller outbreak, but really with Benty being over, we had all the tools and strategies we needed to implement another cerclage. It was clear that that was the way to go, even though there was a lot of hesitancy at the beginning. It was very intense, resource intensive, and you had to have people sleep in the villages and all these things. But that was the strategy that was deemed to be working, so that's what was applied. Benty is the one that solidified all the details. We were able to pull it off for seven or eight villages, so every other place was--we had a book to follow now.

Q: I'm wondering--can you describe some of the individuals in a little more 02:45:00detail, like the prefectural coordinator, or just anybody who you worked with a lot.

GHISELLI: The prefectural coordinator [Dr. Batchily], very big guy, very loud guy, but clearly also a very decisive, authoritative figure. Which was quite refreshing, to be honest, to see a local authority take such charge and be in such clear leadership. He had the WHO and UNICEF field coordinator at his sides, but it was very clear that he was in the leadership position, which was very nice. It made it so much easier to just go to him, this is what I'm thinking, yes, no, move on. Very authoritative figure, very well-respected. I think he's still there in Forecariah, I think. But has done quite well, and was well-regarded. Also very much a field man kind of thing. The UNICEF field coordinator also, Dr. Cisse. Ibrahim Cisse. Usually between WHO and UNICEF 02:46:00there's a bit of a rivalry. Probably more than a bit. And yet, I found him a great person to work with. The social mobilization pillar was often chaotic, but he demonstrated clear leadership and actually managed to make things happen according to the overall strategy. His social mobilizers were in place, and he helped out in a number of issues, like malnutrition cases. He was also--he was from--I want to say Mali, but he was very good. A kind person, too, so it was very easy to get along with him. He was staying at our same hotel, so we often had dinner together, the whole team of us. Compared to our relationship with UNICEF in Sierra Leone, this was a much more amicable relationship and much, 02:47:00much easier to discuss and decide together what we wanted to do.

The WHO field coordinator, [Dr. Mouctar Diallo]--funny guy. No, he was very good. He taught me the value of saying thank you to people and how much it motivates people to be thanked, because he did it all the time, and you can just see the sparkle in the field epis' [epidemiologists'] eyes when someone recognized how much their work was. He's the one who called them patriots. He is this small guy. He was from the northern part of Guinea. A Guinean, but he looked completely different. It was more of a Tuareg kind of look [(lighter skin)]. He stood out a little bit, but he was clearly Guinean. Poor guy. He was WHO international staff in Central African Republic. He goes home for a little bit to rest, and they say, go check out that thing in Gueckedou that's 02:48:00happening. While you're on break. And of course he gets sucked into Ebola in Gueckedou. And then, finally when that's over, he goes back to Conakry, hoping to spend a little bit of time with his family. It's like, no no no, now you go to Forecariah. And with the new baby, he was always back and forth, back and forth with Conakry. So it was very difficult for him. But he was also quite a leader and a good guy. Mouctar Diallo. A good guy. I know that other people at CDC didn't like him as much, but I worked with him day in and day out, and he was solid. He was solid, and he was exactly what was needed in Forecariah. Just something adaptable and someone who can inspire people. He did inspire people more than any other person I've seen. In these conditions, you need to be 02:49:00inspired, otherwise you can't do it. You just can't do it. You need to know that someone appreciates what you're doing. And he always would start with thanks. I think that was incredibly valuable because, again, Guinea received very little support internationally. It was the Guineans and the Congolese [FETP graduates], and someone needed to tell them that they were doing a good job.

Q: There were CDC people out there with you?

GHISELLI: Yes. They came towards the end.

Q: Towards the end, okay.

GHISELLI: Towards the end of my stay in August. But I don't remember them--I--no, no that's not true. There was two people who came with me to Benty every single day until they left and they did everything they could. They were part of the team. Other people came in later, but again, they stayed for about a week or so, or ten days, so they were never fully integrated into the activities. The other two people--one is a CDC staffer who is actually a 02:50:00colleague of mine now. And the other one was a contractor whose contract has ended with CDC. She was part of the Ebola response team specifically for Guinea. She traveled to Guinea frequently, and she was with me every day. But it was mostly a WHO, MSF response.

Q: Is there anything that we haven't discussed regarding this time in Guinea that is important?

GHISELLI: I can't think of anything. I'm sure it will come to me in a moment. But these are the main points. Benty was certainly the biggest, biggest issue that we had. I was glad to be--I pushed back my departure by a month just to make sure that we could be there to wrap it up and finish it up. It was incredibly intense, especially when you start putting people on the ambulances and everyone behaves like they're never going to see them again. It's their 02:51:00hearse more than their ambulance. That was sometimes very difficult, just to see people just give up, say, "I'll never see this person again." And with cause, knowing how many had died before. But it was also very, very nice to know that things had been wrapped up nicely, and that no more cases happened in Benty since. No more have happened since.

Q: What happens after you leave in August?

GHISELLI: I go back to Gabon for three weeks. Go back to the States for about a week or two. Then I go back to Gabon. At that point, in Guinea I got called by a new team in CDC, the Global Rapid Response Team, saying, "You should submit your application because we're forming a new team." So I type up something and I send it in. And we do an interview. It's just like, well, you know, it's a new team. There's a lot of room for new developments, and there is a lot of room for 02:52:00deployments for different things. It actually would be your job, not taking you out for anything else. So I'm back in Gabon, and thinking [it over]--because admittedly secondee life is quite sweet. You get a house from the embassy, you travel as a UN staffer. There's a lot of perks. You're associated with the embassy, you're working abroad, the workload is not that intense. There are a lot of perks. On the other hand, the idea of continuing with this work and the emergency response, knowing that will never be as intense as Ebola, hopefully. But that it could be. So basically by the end, the day before I leave for the States, I make my decision and I accept the job with the GRRT [Global Rapid Response Team]. Then I have six more months in Gabon. I do one more mission in Equatorial Guinea, six weeks at the very end. Then I go home for ten days, pack, 02:53:00and at the beginning of March, I'm here.

Q: Beginning of March of 2016?

GHISELLI: Sixteen, yes indeed.

Q: That's right. And it was only a month later when you get back to Guinea, is that right?

GHISELLI: Yes, indeed. This time is with CDC and with GRRT. We have these ten cases in Guinee Forestiere and Nzerekore. And now infection in Liberia. Everyone is incredibly concerned. So--you've been there before, you speak French, go. It's like, okay. So I arrive there, and the first thing--I meet with Ben Dahl, whom I had known from GID. He says, "Our epi team lead is leaving. You're it. She's going on vacation, so we need someone to replace her for the time." Okay. I had never done anything at the national level for the Ebola response. Certainly nothing for CDC. So it's a new organization and a new level. 02:54:00Fortunately the disease I already know, and I know the language. Again, CDC WHO at this point were very much integrated. I can pop over to WHO offices and I know everyone. A lot of people from the FETP DRC cohort are now back in country, so I get to see them as well, which was really good. So I'm epi team lead. One of the first things I do is go to Nzerekore to see what's happening. And what is happening is basically the response is over even before the twenty-one days are up. There just wasn't--people had understood that the outbreak was limited to these ten cases in Guinea and three in Liberia. They were all linked. We were following the contacts but no one was showing any signs of disease. It was clear that we were wrapping up. My job in Nzerekore then was to dismantle the CDC team 02:55:00and decide who was going to stay, and to do what. So we had two people stay. One to continue following the epidemiological situation, do active case search and strengthen surveillance for other diseases as well, and the other one is to follow the trials of the RDT [rapid diagnostic test] for Ebola, keep doing the testing, keep reporting the results, making sure that the protocols are being followed. I leave these two people in Nzerekore. And after about a week head back to Conakry.

At that point, we have a new team--new response lead. Michael [H.] Kinzer who is the CDC country director for Senegal. He was there before twice as response lead, but in 2014. Now he's back to close up the CDC response for Ebola and offer some support to the new country office as well. Because the county office is only two people, and he has experience setting up a country office because 02:56:00when he arrived in Senegal, he was a team of one. So he's helping them out as well, just from an advisory point of view. We also have Kevin [M.] De Cock, who is the CDC country director for Kenya, who has also been a response lead for Liberia I don't know how many times. We have both of them in country for both Ebola and an advisory role for the new country office. Kevin De Cock stays for about ten days. He doesn't feel his role is very much needed, and he has a big country office to run. But I'm sure--I know he gave some very, very valuable advice, strong advice, to the country office. Obviously his input into the response was great.

Q: Do you know what that advice might have been?

GHISELLI: I think more than anything was for the country office to move into the embassy, just to make life easier on everyone. Because right now the country office is in a building that is rented by USAID [United States Agency for International Development], but that building is being dismantled soon. They 02:57:00always have this difficulty with getting in touch with the embassy because it's so far and the traffic is so bad. The biggest advice is move back to the embassy, and from there you can move in a position of strength. You know how supportive the embassy has been of the response. It's a good place to be. All the logistics of setting up a country office work well if you have embassy staff next to you to answer your questions. But one thing that Kevin said that struck me was that he was saying the same thing that I saw in Sierra Leone. "The response in Guinea is not so bad. It's actually quite good. I had not realized how much work you guys were doing, and how well it was going, and how efficient you guys were with far fewer resources." So it was good to get some validation from Dr. De Cock as well.

When I came back to Nzerekore, Mike Kinzer said, "You be my deputy." It was like, okay. So, deputy response lead. Again, never having done it at the 02:58:00national level, but so far so good. In reality, our biggest job was to help out with the transition. What do we do now that Ebola is pretty much done? Aside from obviously intensive surveillance all the time, everywhere. What do we do? As Michael said, how do we add value to the response and to the recovery efforts? Which I thought was a very interesting question coming from WHO, because WHO never asks what is our added value to the response. We are the response. We don't need to add value, we are the response. Everyone else is a corollary to us. So to hear this question from the CDC side was very interesting to me. It was like something I kind of, sort of thought about, but not really, and certainly not in any concrete context. How do we add value? What do we do 02:59:00that is different from being a WHO appendix, but does not interfere with the WHO-Ministry of Health relationship? Where do we position ourselves? I think this is also a question that I--now that I've been to Angola for two months with CDC, that is a question that comes up often to me. My natural tendency is to work with WHO very closely, and in this case, in Angola, it worked really well. But another person might decide that CDC should be completely separate and have their own projects, which is equally valid. We have bilateral relationships with the ministries of health in all the countries where we serve. So we could be completely separate from WHO, or we can be completely enmeshed. We can be somewhere in between. I think that's a question that comes up more and more as CDC becomes more global. I don't think there's a one answer. At least I ask 03:00:00every country director I meet, and I don't hear the same answer. Which is good. Flexibility is needed in different countries, different contexts. And also there might be some country offices with whom it's just impossible to work, and some others where it's very natural.

But basically what we did to add value to the response was the RDT trials. The RDT project, trying to understand whether that works and under which conditions. Especially now that we can afford to not be so focused on the areas where the outbreak occurred, where do we want to be with this RDT? How do we want to spread it out? How do we want information to flow back to us? Just assess really whether this test offers any significant additional value to any future Ebola response. That was a big project with us, big project.

Then, obviously, continue doing active surveillance. This was at a point--a very 03:01:00unfortunate point. Because the cases in Nzerekore came almost on the ninetieth day from the last Ebola case in Guinea. The response was already being dismantled completely. A lot of people had been let go from the different partners. And now we have cases, and you have to--we don't have money to rehire all these people. All our funding streams are going to stop in two days. The clock is set. What do we do? We need people. So unfortunately, WHO had to let a lot of people go. They worked very hard to rehire as many as they could right away. I think they did a very good job, and they sent them off to Nzerekore. But in Conakry, for example, there was a huge vacuum. WHO just left. And having been WHO, and you're supposed to be the first and foremost partner of the Ministry of Health, that leaves a huge gap. So part of my role was also to help our field 03:02:00epidemiologists understand what WHO's role usually is, and how to not take over, definitely not take over, because WHO is coming back and they're here far longer than we are. But to complement, as much as possible, what WHO was doing and immediately reintegrate WHO once they were back. They started coming back even in the month when I was there, just trickling one by one. They were coming back to the different communes and to the different sub-prefectures. They were coming back, but depending on the rehiring process.

In the meantime, CDC had to carry the brunt of the field epidemiology and active surveillance. How do you do that, when such an important partner as WHO is not there? The one who has all the relationships with the local authorities, with the local hospitals, the ones who are there for the longest period of time? Because my CDC staffers are mostly from DRC. I have five people from Guinea for 03:03:00Conakry. And the other teams are made up of Congolese. So these are not even locals. It's not as bad as sending myself, but it's still pretty obvious that we're sending foreigners to ask sometimes invasive questions. It was a pretty delicate moment for a couple of weeks. Fortunately, WHO started sending their people back into the communes and the sub-prefecture. So we were able to stabilize the situation while WHO got back on track.

Q: Were there specifically kind of delicate moments that you remember where, you know, people from outside the communities were coming in and asking invasive questions?

GHISELLI: We learned--people from the community--no, they were not asking questions. It was more us asking invasive questions--

Q: I'm sorry, that's how I meant to phrase it.

GHISELLI: --us as foreigners. We--well, a lot of times we had this one woman who was coming from--I can't remember which prefecture. But there had been a case there--she was coming from Nzerekore. And she was in Conakry. She showed up with a fever to a hospital, but then when someone mentioned the word "evacuation," she completely disappeared. So we were out on a hunt through the communes of Conakry, trying to identify this woman. Then we finally identified her and sent there the commune official to talk to her to try to convince her. In the end we finally managed to get her tested, and she was negative. But that's one instance where I purposely kept my team members back and let them help the authorities from afar. I really didn't want anyone from Canada or Congo to be the one 03:05:00telling this Guinean woman, get in an ambulance. So I purposely kept my people back on that one, and I think it was the right thing to do because then the local authorities spoke to the woman. It took a couple of days, but she was already isolated in her own room, so it wasn't a critical situation. It took a couple of days to bring her out, but it was done and she was negative.

Q: That helps to hear about. Were there individuals from Congo or from Canada who stand out to you when you look back?

GHISELLI: We only had one from Canada. So the PHAC. The Public Health--

Q: Agency of Ca--

GHISELLI: --of Canada, yep. Only one of them. She was very good, very eager. Unfortunately, very blond. She like me stands out very much. But she was very, 03:06:00very--she was in Matoto, a commune, with a team. And she really strived to do her best. She was very good at it. She did manage to extend for two weeks, so I was glad about that. For Congo, there's this one colleague, and now friend, Jean-Paul Moke. He was with me in Forecariah and did an amazing job. Again, the kind of guy you want in a crisis. Cool, calm, collected. Very strategic, very systematic. Started out the whole investigation process in Benty. You go here, you go here, and these are our three axes to follow. And I met him again. He was still in Forecariah when I came back to Conakry, so we only spoke over the phone. But he was the same type of, active case search, what can we do to improve things. Really, really the kind of guy you can send to a place and say, tell me what's happening, and you get a clear report of what's happening along 03:07:00with the issues and proposed solutions. So now we're trying to have him hired as resident advisor for the FETP program in Guinea, because he is a graduate of the FETP program in DRC. He's the kind of guy who would be excellent for this kind of leadership position. So we're trying. It's going through the system. It's moving through the system.

Q: Can I also ask, were you ever to--were you ever able to revisit Forecariah, and--

GHISELLI: No, unfortunately, no. I really wanted to, but it would have taken a whole day. Well, a whole day going, and then a whole day back. There was no justifiable reason for me to go. There was nothing much happening there anyway. I spoke with Jean-Paul frequently on the phone, so I knew what was happening and I sent my best and everything. But no, I was not able to go back. I saw another piece of Guinea in Nzerekore.

Q: Were you able to wrap up the--I keep on using that. I'm sorry, it's annoying 03:08:00phrasing--the transmission cycles before you take off?

GHISELLI: Yeah. For those ten in Nzerekore, yes.

Q: Great.

GHISELLI: Yeah, and the three in Liberia. They were all part of the same chain. But it was pretty clear even before I arrived that this was the complete chain and nothing further had spilled. Our focus really in Conakry was more maintain active surveillance and what do we do for recovery. A big piece of the recovery was healthcare for the survivors and testing of survivors. That was a huge piece of it. That's where we worked very closely with WHO, so with my old colleagues in trying to figure out what this would look like. How do we help the government, the Ministry of Health, and craft this proposal to the government? How do we select which activities do we want to present to donors, so that we 03:09:00have the maximum chance of getting these things funded? Because the idea was to provide free healthcare for life to survivors, their families, and the volunteers in the ETUs and the Red Cross volunteers. Absolutely, no one deserves it more. How do we finance this? I think in the end it was just survivors and the volunteers. And then, what kind of care are we talking about? Because we had specialized centers across the country, but a lot of times these people can't travel that far. So what kind of ambulances, or transportation, or payments, things like those. When I left, we were getting into the nitty-gritty of these things. But the big, big push was healthcare for survivors and the volunteers. Trying to recognize as much as possible their amazing efforts, especially the volunteers.

Q: Do you feel you were able to accomplish the provision of future healthcare?

GHISELLI: We definitely talked about it. It was on a good path when I left. I know that that was something that the country office, CDC country office, was very keen on as well. I'm sure they kept on going as well. So yeah. But it was a very different experience. We actually had time for lunch, which is incredible compared to Forecariah and Kambia. They never had time for lunch.

Q: Did you eat nothing? Or did you eat CLIF Bars?

GHISELLI: Well, in Kambia, not even. In Forecariah, yes, there was a little bit--no, we actually--Forecariah was funny. Once we left the dirt road and actually started on the main road, we would always stop at the first town, the one right on the border [Farmoriah], and buy a baguette and Coke. That was lunch, at 2:00, 3:00 in the afternoon, 3:00 or 3:30 in the afternoon. Tasted 03:11:00wonderful. But that was our lunch in Forecariah, yes. Then at the hotel it would be chicken and chips, usually. But in Forecariah, no--excuse me, in Conakry, no, you had time for lunch. You got to meet people, and more relaxed spaces. You could actually take an evening off once in a while. It was lovely. It was lovely, yet it was very different. But I was very glad to be there to see it wrapped up. The whole response, the whole Ebola response just wrapped up. And reflecting back on how desperate it seemed at the beginning of 2015, when people are just dying all around us, and now we're back here in Conakry which had been one of the epicenters, and be able to take time off during the Ebola response. It felt like we had come lightyears. And we had. We were able to put survivors at the center, rather than worrying about the bodies.

Q: Slightly more cheerful.

GHISELLI: Slightly more cheerful. Definitely more cheerful. Definitely more cheerful. And it was weird to just stay for only a month, but it was a good period of time to be away.

Q: So when you reflect back on your entire Ebola response experiences, what do you think about?

GHISELLI: It was certainly the most meaningful thing I've ever done. It definitely changed the way I want to do public health in an international setting. But it also makes me realize how fragile things are in terms of systems. How much all of these outbreaks, not only Ebola, but also yellow fever and Zika, is dependent on climate change and urbanization and things that are way beyond the control of public health. And also makes you realize how much 03:13:00work can be done with close to no resources, because Kambia and Forecariah didn't really have a healthcare system before we started. I know WHO got a lot of criticism because we started late. But in reality, being the partner of the Ministry of Health, we can't move without the Ministry of Health. And if the Ministry of Health is nowhere near mounting a response, there's nothing we can do. We are advisors, we don't dictate anything. We can advise, we can suggest and strongly recommend, but we can't do anything more. Until the Ministry of Health was able with the support of partners to mount a response, then we were able to fully intervene. And really, when I arrived in 2015 in Sierra Leone, that's when things were really starting to kick into gear. That's when we had the cars. We could have--deployed the personnel. They could send us fuel as much as we wanted. All of that was not possible in 2014.

Q: Is there anything else that you'd like to make sure that we have on the record?

GHISELLI: Just that all of our participation, CDC, WHO, all of it, pales in comparison to what the Guineans and the Sierra Leoneans have done for their own country. Sometimes we say that in Africa people are lazy, or we say that they don't know how to take care of themselves, or there's no culture of volunteering. I have never seen anything like it. The complete, utter dedication to one's own country at risk of their own lives and their own families. That is nothing that we can ever hope to rival. And that needs to go on the record, because they--I cannot speak for Liberia, but I'm sure it was the exact same thing. But yes, true patriots.

Q: Thank you, Margherita. It's been so great having you here.

GHISELLI: Thank you very much.

[break]

GHISELLI: I think CDC [staffers] had it much easier. Staying at the Radisson, staying at the Palm Camayenne. Being able to choose whether or not you get deployed. Being all volunteers, getting overtime comp. These are things that WHO does not have. In all honesty, I think WHO did as much as they could with the resources that AFRO gave them. But I also will say that I was quite disappointed how few AFRO staffers participated in this response. When we were desperate for Francophones--my office is all Francophone. All the countries we serve are Francophone, and very few came. So I mean, yes. There were drawbacks on both agencies, but CDC had it a little bit easier.

Q: What do you attribute that to? The lower participation of AFRO?

GHISELLI: Because we were deployed, there was no volunteer spirit. There was no "I'm doing this for my region." It doesn't affect me, it doesn't affect my family. I'm not getting anything out of this. Except, you know, for per diem, and I can get that going elsewhere. I think AFRO could have done a better job at sending people. On the other hand, AFRO regional office needed to keep on going with the other diseases. So they were a bit in a bind as well, because there are jobs that only people--AFRO staff can do. While being a volunteer almost anyone can do. But I was a bit disappointed to not see more engagement at all levels. And on the CDC side, I was hearing that there was a huge, huge problem finding Francophones--

Q: Yeah, there was.

GHISELLI: --to go. And some people went six or seven times, or something like 03:17:00that. That too to me was strange. Well, not as strange as volunteering to go and then insisting on staying at the hotel.

Q: You heard about that?

GHISELLI: I did.

Q: Oof.

GHISELLI: Yes. We heard about that. And--

Q: In both Guinea and Sierra Leone?

GHISELLI: Yeah.

[break]

GHISELLI: But on the other hand, everyone who came to Kambia from CDC loved it and wanted to stay longer. So, in a sense, yes, there was the idea of--it's hard, it's difficult, it's dusty. But you can see so quickly what your impact is.

[break]

GHISELLI: Of course, leadership, in--even Conakry can serve its purposes sometimes, even though I railed against it so much in Forecariah. But if you are truly in a leadership coordination position, then yes, of course. Then, of course, you should stay in Conakry, or in the capital, or wherever. But if your 03:18:00role is more to work on this project or that--yeah. In all honesty, even I, being in Conakry now in April, it's an interesting cognitive dissonance to go out into the neighborhoods, into the shantytowns, and then go back to the Palm Camayenne and act like nothing has happened. We live in a white fortress with a pool, and yet we know so well how other people live. It's something--because I did it, too, in Conakry in April. But it always struck me as, why don't we feel it more? Also because, at the Palm Camayenne, very cleverly, all the hotel rooms face the ocean. None of them are facing the shantytown, which is right across the street. So you only get to see the shantytown when you're walking in a corridor. So it was even more built to shield the guests away from the ugliness 03:19:00of the city. But, again, I--

Q: Do you ever--were there ever organized group efforts to just recognize that disparity, and--no?

GHISELLI: No.

Q: Just on an individual basis you kind of have to--

GHISELLI: Yeah. Yeah. I mean, I think what most CDCers did to try to bridge the gap was train the hotel staff in proper wash--hand sanitation. And their reasoning was very good. People who work at these hotels usually are the breadwinners for their families, extended families, too. So if they set the good example others will follow. And they don't live in nice neighborhoods. They live in the shantytowns as well. So the reasoning was good.

And then the limitations we have from the embassy, in terms of movements and where we get to stay, obviously create a barrier between us and the people we try to serve. And that--the more I travel, the more I see it. And there doesn't seem to be a way around it. So it's just--it just adds to the cognitive 03:20:00dissonance. And sometimes you forget about it, but sometimes it's very, very stark as a difference. And we're not allowed to do anything different, but I don't even know if we would want to do anything different. Or at least the majority of us. It's a nice five-star hotel. The food is really good. You get salads, for heaven's sake.

Q: Oh, salads!

END