Mohamed Jalloh

Mohamed F. Jalloh

Q: This is Sam Robson here with Mohamed Jalloh. Today's date is March 4th, 2016, and we're in the audio recording studio here at CDC's [United States Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Mohamed today as part of the Ebola [Response] Oral History Project and we'll be discussing briefly his life and career leading up to the Ebola epidemic and then really digging into his response to the 2014 West African epidemic. Mohamed, for the record, could you please state your full name and your current position with CDC?

JALLOH: My name is Mohamed Falilu Jalloh and I am an epidemiologist within the Division of Global Health Protection in the Center for Global Health here at CDC.

Q: Thank you. Where and when were you born?

JALLOH: I was born on March 4th, today actually, so it's my birthday--

Q: Happy birthday.

JALLOH: --1985 in Makeni, Sierra Leone, thirty-one years ago.

Q: Tell me about growing up.

JALLOH: I was born in Makeni in Sierra Leone, stayed there until I was about one--so I have like no memory of that time--and then went to the capital of Freetown in Sierra Leone and stayed there for most of my young years, until the age of thirteen. I went to school in Sierra Leone. I went to Akibo-Betts primary school and then from there I went to Limount College, because in Sierra Leone after the sixth grade you then go to what you would consider here as middle school, but there it's secondary school. I started secondary school there in 1998 and then stayed until 1999. It was a very interesting time in Sierra Leone during that period because the war in Sierra Leone started in the early nineties, but in the early nineties the war was still in the eastern part of 00:02:00Sierra Leone. Started in the Kailahun area, which is the same part of Sierra Leone where Ebola came into the country from Guinea, so that is a very interesting part of Sierra Leone.

By 1997, there was an overthrow of the government and then my family moved out of Freetown to Kambia. Over there, my dad was working with UNICEF [United Nations Children's Emergency Fund] at that time and actually he was the officer in charge for UNICEF in Sierra Leone. After all the international staff had left, he was responsible for the office and the office had moved to Kambia. All the international staff were now in Guinea, so we stayed in Kambia for about a year and then we went back to Freetown after they reinstated the President, [Alhaji Ahmad] Tejan Kabbah, who had been overthrown. They reinstated him back in power in 1998, so then we moved back to Freetown and that's when I started my 00:03:00secondary school education at Limount College. After the first year of staying in Freetown after returning back from Kambia, then the war finally hit Freetown. I was there with my family. So like I said, that was a very interesting period. We had heard a lot about the war from the experiences of others who were in Kailahun, Kono and other parts of Sierra Leone. Those of us living in Freetown, in the capital city, had never experienced the war or anything like it, so that was the first time that we went through that experience. It was a very unique experience as you can imagine that really shapes the way you see the world and the way you understand things, etcetera, etcetera.

Q: Can you tell me a few memories that stand out about that period?

JALLOH: It was one of those periods--in a way it's kind of similar to Ebola, and 00:04:00we can talk about that a little bit more--in the sense that there was a lot of uncertainty and it was a new experience. Especially for people like us who had never experienced the war firsthand like those who probably lived in other parts of Sierra Leone like Kailahun or something like that or Segbwema. Those are the hard-hit places in terms of the war. Koidu. Freetown, life was pretty normal, so again, it was a new experience, it was a violent experience, and it was a devastating experience. I remember the very first night when they attacked Freetown. It was a very, very--how can I describe it--uncertain experience. It was a life or death experience. You weren't sure if you were going to make it. I was young, I was only thirteen at that time, but at the age of thirteen you still have a pretty good understanding of what's going on. The rebels attacked, the RUF, the Revolutionary United Front, they attacked at 2:00 am. This was the 00:05:00middle of Ramadan and Sierra Leone has a Muslim population of about sixty-five to seventy-five percent, so a lot of people were preparing for the next day of fasting. At around eleven o' clock we had finished preparing, eating up a lot and just getting ready for the next day of fasting, and then we saw a lot of people coming from this part of town called Waterloo, by the eastern part of town. It was a huge crowd, like an exodus of people just leaving that part and then coming, and they kept telling us that the rebels are really close. They are closing in on Freetown. We didn't know what to do at that time. A lot of our relatives had moved into our house because they thought that it would probably give better protection because it was a cement house. They were there living with us, probably about thirty people in the house, so you can imagine it was 00:06:00jam-packed. And then how to figure out a way to leave.

Fortunately, there were several cars around, so we made what we could of it. Luckily, there was this one bus that my dad had, they were using it as public transportation for a while, but then we converted it and used it to like move out. As we were moving out, we got to a place called Grass Field by Kissy area and everything just stopped. Like thousands and thousands of people, and the traffic stopped, and the reason for that was they had the ECOMOG [Economic Community of West African States Monitoring Group] force, so that was the West African peacekeeping force. They had a checkpoint that they had put up and they weren't letting people go through because they weren't sure who the civilians were and who the rebels were. So we were all just like stagnated there for a while. As were sitting there waiting, it was very, very loud--this was like 2:00 00:07:00am, but it was very loud. You can't even imagine that it was 2:00 am, and all of a sudden we heard the first gunshot. It felt like it was someone just standing right behind me that shot that.

All hell broke loose--people were running around. We got out of the car, me and my dad. At that time, I was very young, so my dad held onto me and then we were ducking and running around and people were getting shot right in front of us. We ran and sat by this little--some drainage, that's where we hid. We were sitting in there and I remember sitting there and then it was like looking up in the sky and you can just see bullets flying in all directions. It was really, really bright because of all the gunshots. It was really bright, it felt like it was like a bright, summer afternoon. Mind you, this was like 2:00 am at night. The 00:08:00noise, the chaos, people yelling, people getting killed. I remember sitting in that drainage system and I told my dad, I said, "If we sit here"--because even though it was a drainage system it was open, so we were quite exposed. At that time, I guess he was very confused. For me, I was relatively young, but he was worrying about what was happening to the rest of the family because at that point we had been separated from my mom, my brothers and my sisters and the rest of the family. We had no clue where they were, they had no clue where we were. It was just me and my dad.

There was a house right across from where we were hiding. I said, "I think we should go to that house and see if we can stay in there." He was like "No, we'll just stay here." We stayed there for a little while and then eventually he said, "You know what, you're right, we should." So we crawled, literally crawled on the ground over to the next house. We got there, we knocked on the door and as you can imagine, they were skeptical because they didn't know who we were and they kept quiet for like five minutes. We kept knocking and knocking and then 00:09:00someone whispered and said, "Who's there?" We said, "It's just us, we're civilians, we're stuck out here, can you please let us in?" Then they opened the door. When we got in there you had like two hundred people in this one house because I guess a lot of people had run into that house to find safety. We went in there and everyone just found a little spot, just lay there, sat there. The gunshot and exchange of firing went on for a while and then they burnt down all the cars outside. Literally, you could feel the heat where you were laying or sitting. Eventually, that passed by. Nature happens, I fell asleep. [laughs] Sleep, you can't control, and then maybe for just a few hours though--one or two hours you just pass out and then we woke up and realized, wow, this is not a dream, this is really happening.

We went outside and the same place where we were hiding, in that drainage system I was telling you about, there were like ten people laying there dead. You walk 00:10:00outside, there was just dead people everywhere. As we were walking by, at this time we had no clue where the family was. They were close to us in a different car, but they had gone somewhere else, we had no clue. We were walking around looking to see if they were among the dead. You can imagine how traumatic that must have been. I remember seeing this one young girl, she looked like my sister. I thought that might have been my sister. We went there and looked and it wasn't her. We couldn't tell because she was laying on one side of her face. When she was turned around, the other side of her face was all gone because I guess that's where she got shot. So you can imagine, it was very graphic, it was very, very traumatic.

We left there, went to our house. We waited there until the evening. We had no clue where the family was. I think we fell asleep again. We ate. That's all you could do at that time and then a few hours later, around 6:00 pm--because our 00:11:00house was kind of like on a hillside, so we saw people coming up. It looked like it could be our family members. We said hey, that's them, and I remember we were on the second floor of the house. My dad almost jumped to go down to see who's there, who's not there--he was so anxious. We had to grab him and say, that's not the way to get downstairs, you can take the stairs. He took the stairs, we all went down and you can tell that initial moment where--like I mentioned before, we had about twenty other family members who had joined us. So trying to figure out who's there, who's not there, who's missing, who might be dead. In that initial instant you're scanning through everyone very quickly to see and you're not sure. Eventually, everyone was accounted for and everyone was well and safe, so that was good news. We stayed there much longer, meaning in that house.

Another memorable experience was after maybe about three weeks or so of the 00:12:00rebels trying to take over the capital, they were very unsuccessful and then they got pushed back by the government. Unfortunately for us, where we were staying in Wellington on the eastern part of Freetown, that part was under the control of the rebels. When their advance to try and take over the capital was unsuccessful, they retreated back to their base. Unfortunately for us, we lived kind of like where their base was in Freetown. As you can imagine, they weren't happy because they weren't successful. As they were retreating they were burning down houses. I remember there was this one evening where we all thought they were going to burn and kill everyone. We were hiding in the house again, once again we had a lot of relatives and neighbors who had moved into the house. As we were waiting in the house, we saw them finally approaching. Literally, they 00:13:00would just go from one end to the other, house by house and they will just burn down every single house, kill whoever they can kill, loot, take whatever they can take and move out. Again, it was a period of uncertainty as we were sitting there waiting and we saw them coming up, climbing up the hill to get to our house. We didn't know what was going to happen when they got there. They got there and we were all hiding inside. They knocked and we tried to act as if we weren't in there. They said, "We know you guys are in there. If you don't open, we're just going to burn everyone in the house." That's when we said "Okay, okay" and then we opened the door. They got in and they asked who the head of the household was, and then my dad presented himself. They said, "Just give us everything you got and then we'll leave and we won't kill anyone." So they went upstairs. I guess whatever savings he had, some money here and there he gave to them. They took whatever they wanted and then they left. So again, everyone could breathe and say okay, [exhales, laughs] this is good, this is good.

We went to sleep and then the next morning they showed up again, but this time you can tell there was something different. They came back for a reason. Usually, once they leave a house, they take whatever they need, they don't come back. When they came back, I remember we were sitting in the front of the house, some of us. My dad had gone downstairs to check up on some neighbors who had some situation going on, so he wasn't there. They walked in, and you could tell it was a senior-level person that came back. He must have been like a captain or something like that. He had a squad of maybe twenty people, twenty of his men that came. They were heavily armed and they came out sitting in the front of the house with my cousins and my sisters and some other family members and they said, "We're looking for Mr. Jalloh." That was exactly what they said, and we 00:15:00said, "He's downstairs" and we pointed to there. They say "Oh, he is there, said "Okay. No one leave, stay where you are," and then they went down there.

I was young at that time, but my instinct told me that something wasn't right. I told my cousins--my older cousins and my sister and some of my other family members that, "This doesn't seem right. I think this is going to be a bad situation, we should find a way to escape if we can." One of my cousins, he said, "No, no, no, no, no. They're just here to probably get more money or something like that." I said, "No, I think they took all the money they can take. This doesn't look good." Then he said, "No, people, there's no need to panic." I got up and my other cousin came with me. My sister was going to come with me, but my cousin said, "No, no, no, don't come" or whatever. Anyway, I said, "I'm leaving." I literally just walked out without making a scene. They saw me. Maybe they didn't pay attention because I was young and I just walked 00:16:00out of the house and went up by a little hillside. I could still see what was happening.

From my understanding of what happened after talking to my family, was that they went and met with my dad and they asked, "You are Mr. Jalloh?" And he said, "Yes." They said, "Okay," he introduced himself and said, "I'm Captain--" I don't remember his name, but "I'm here, and I'm here to kill you and everyone in this house." That's exactly what he said. He said, "The reason for that is because out of all the things we took from the house, we found a business card for the Minister of Defense, so we are convinced that you are affiliated with this government. We've asked people around and they believe that you're working with the government." I mean he was working with UNICEF, so out of--maybe you can call it ignorance, they probably thought there was a link between UNICEF and the government or whatever, and then having this business card didn't help. Unfortunately for my dad, it's not even a business card that he had. Someone else had left their briefcase there because they had important documents for 00:17:00safekeeping and it was a family friend. He was actually working for the Minister of Defense. So actually, it was his briefcase that had all these government documents in there and business cards and things like that, but there was no way of convincing them otherwise. So he said, "Okay, we're going to take you and we're going to kill you and all of your family."

So then they brought him upstairs and they said, "Before we kill you, first we're going to burn the house. We're going to put the house on fire so you will know that we're serious about this," and then they lit the house on fire with the first floor. As the house started burning, there was a cement block there and they said, "Okay, sit on that cement block, we're going to execute you in front of everyone." So they sat there, and people were crying and all the neighbors were like, he's a good man, don't kill him, blah, blah, blah. As he pointed a gun at my dad, he was going to shoot him, he said, "You know what, I can't do this here. There's too many people here. It seems like you know a lot of people, so what I'm going to do, I'm going to take you and I'm going to 00:18:00select some other people that we're going to take back to our base and that's where we're going to go kill you." Then they pointed to like my dad and then my mom, they said, "You, we won't take." Literally, they were hand-picking who they were going to take to go and kill. They took my dad, my oldest sister, some of my cousins, a group of like ten. Then like another ten people they said, "You guys are the lucky ones, you can go." So they took them, the house was burning and then they took them to the camp.

There was an interesting story as they were going there. My dad actually, he was walking barefoot and it was really, really hot as you can imagine. That was like a very crazy experience for him as you can imagine, but in that moment you're not thinking about that, right? As he was walking--so the rebels saw this chicken that was running around and they were trying to like catch the chicken and then my dad was trying to make a good gesture and, "Oh, I can help you guys catch it." You can imagine, this is someone who is the officer in charge for 00:19:00UNICEF, walking barefoot now trying to help these rebels catch a chicken just to be on their side to kind of gain favor. So as he was trying to do that they said "Oh no, no, no, leave that chicken alone. That chicken's life is more valuable than yours right now." That's exactly what they said to him. They walked over to their base and sat there. As they were walking by, the captain started--I don't know if he just needed someone to talk to--started talking to my dad, asking him what do you do, and he was explaining to him. He had worked for UNICEF for a while and been through a lot of security trainings on how to negotiate with captors or whatever because they kind of knew things like that could happen. So he was talking back, he saw it as an opportunity to start talking to the captain and build that relationship. The captain was asking him questions, he was asking the captain questions.

The captain told him, "The reason why we're doing this, we're very disgruntled. 00:20:00The government doesn't care about us," blah, blah, blah. He was pretty much explaining the rationale for the war, and as he was doing that my dad engaged him in that conversation and asked about their life and made it very personal. The guy asked my dad, "So what tribe do you belong to?" Told him, "I'm Fula." The guy said "Oh, my mom is also Fula," my dad is this, and then they started building that relationship. Told him how long he'd been in the military, when he left the military and joined the rebels. They started building that relationship, that rapport--talking to each other, getting to know each other. Then he told my dad, "I have to be very honest, this is a very bizarre situation for me because the plan was to come back that same night actually after we had left and saw those documents, to come back in the middle of the night and kill everyone. But something, maybe it was God that was on your side or something. We came back, we couldn't find the house. We looked for like two hours in the middle of the night. We couldn't find that house, and then today, I came there, 00:21:00my plan was very clear to just execute you and everyone else. Something just held me back, I couldn't do it. Now, as we're walking by a lot of these neighbors are crying. Something tells me that you're a good person. I can't figure it out." So my dad was almost happy. And he said, "But I'm still going to kill you." [laughs] You're still trying to convince--it was a bizarre situation when my dad was explaining this to us. They got to the base and they sat there. They offered him water, it's a weird situation. You don't know if the water has been poisoned. That's what my dad was thinking. Maybe they've put something in there, you can't say no because they're trying to be nice. So, they drank the water. They sat there and they chatted for an hour. This guy just needed to talk to someone. He was explaining to my dad and my dad was almost counseling him--explaining that, "You know, I understand why you guys are doing this." You kind of have to do that. So they went through that and then eventually said, "You know what, I've changed my mind. I'm not going to kill you or anyone else. I'm just going to let all of you go." My dad was very confused when he told him 00:22:00you guys can just get up and leave now. He thought maybe it was a game or something, that as soon as they got up they were going to get shot. They got up and they left, nothing happened. They got reunited back with the rest of us and then not long after that, the peacekeeping forces came and liberated that area.

From that point on, we left, went to Guinea. I was in Guinea for about six months. I did some school there. From there, my dad got offered a short-term position first to UNICEF New York, so he was there for about three months, and at the end of that short-term appointment then he was given a more long-term appointment to work at UNICEF headquarters in New York, doing communication work for UNICEF. So then, he accepted the job and we all moved to the US and then we settled in New Jersey.

Q: Can I ask one question?

JALLOH: Sure.

Q: So you had walked out of the house, you had walked up the hill or something. 00:23:00Did you see them take your father?

JALLOH: I did. It was hard to explain. You can't really tell because I was far away. For one, I didn't want someone to say "he's also with them" or something like that, so I was pretty far away, but I could see all the chaos that was happening. I could see them walking out and walking away and then after they all walked away--I mean all the neighbors, we had very great neighbors. They came, they put out the fire so the house didn't burn down. Only parts of it burnt down. They put out the fire. Some of them got really damaged in the process. This one guy's ears were burnt as they were trying to put out the fire.

One situation that I left out that was a critical one that happened, it was quite sad. After that incident, we moved away from our house and we moved to my aunt's house. After we had moved to my aunt's house we were short on food 00:24:00supplies, but we had some at the house. There was a gentleman who was very, very popular in that area. He had become friends with my dad, he was a young guy. His name was Justice. Up to now I don't know his real name, they just called him Justice because he stood for justice and he wanted to make sure that everything was right in the community. He built this spring water that he was using to supply water to the community. He was just a really outstanding young guy. He was probably in his late twenties. He had become very close with my dad. After he met my dad, he was like my dad's son. He converted to Islam and everything. My dad didn't convert him, he just liked my dad. He said "Okay, you're a Muslim, you're like my mentor. I want to learn more about Islam." He converted to Islam and then we became very close.

After we moved to my aunt's house we didn't have any food and then he offered to go and get food for the family up to our house. He got the food. As he was 00:25:00coming back he was confronted by one of the RUF rebels. He was literally maybe two hundred meters away from where we were. He was almost there. He got this bag of rice that he was bringing back to us. The rebel that confronted him was actually his friend, they grew up together. He knew this guy. So he didn't take him serious at first. The guy told him, "Halt"--that's what they would say. "Stop! Put the rice down." So he did and then the guy was like, "Leave the rice and walk away." He was like, "Come on, I can't leave this here." He's like, "I know you, man." The guy that stopped him, his name was Bobson. He's like, "I know you Bobson, I'm just taking this to my dad and his family so they can eat." He said, "No, don't move, don't move the rice." He knew this guy, so he didn't take it seriously. The guy told him, "If you take one more step, I'm going to shoot you," and he did and the guy shot him. He shot him on his right leg and he 00:26:00bled to death within just one minute or so. I think that was the worst day of our experience when the news came back that he was dead. We felt a lot of guilt. This was someone that was very close to us. The reason why he got killed was because he was trying to get food for us. That was a very, very sad moment.

Q: I know that there's a lot to dig into here. But just to continue moving forward. You moved to the United States?

JALLOH: Yeah.

Q: Can you take it from there?

JALLOH: We moved to the US in '99--October, 1999. My dad was working with UNICEF and then he commuted from Jersey in Hackensack to New York. We went to school in Hackensack. I went to Hackensack High School. Stayed there, completed high 00:27:00school and then graduated and went to Rutgers University. I did my undergraduate studies there. First, I went to Rutgers-Newark campus and at that time I really didn't know what I wanted to do. I had interest in computer science. I had been doing a lot of web development on my own when I was in high school, kind of self-taught, some graphic design work, so I thought maybe I would do computer science. I started taking the computer sciences classes. Did well, but it was kind of boring, but kept taking them. So I said, maybe I'll do medicine. I was one of those people who didn't know what I wanted to do when I got to college. I liked a lot of different things, so I couldn't settle on one. I was like, you know what, computer science, I have to take a lot of science classes. Medicine, I have to take science classes, so maybe I can just start doing this too. So I started taking my pre-med classes and then my computer science classes and then I left the Newark campus the first year and went to the New Brunswick campus, 00:28:00which is the bigger campus of Rutgers, the second year. I went there and then continued taking computer science classes that first year and then continued also taking a lot of my pre-med classes. But they didn't feel right. I took anthropology, I really liked anthropology because I was able to kind of get a better understanding of cultures because I was really interested in cultural anthropology. I took more of those classes. I really liked it, but I wasn't sure what I would do with that.

Then my dad was in public health and I was explaining to him, because he kept asking me, "What do you want to do?" I said, "I don't know." He said, "Take a public health elective." I was like, "Yeah, I don't know if that's going to be interesting." So then I took a public health elective--Intro to Public Health, and it was fascinating to me. It was very interesting. It was the first time I was able to really understand from a big picture perspective, just even starting 00:29:00with the history of public health. The miasma phase, where people thought that diseases were caused by smell or things that were happening in the environment. When they were seeing cases of malaria they thought well, maybe it was because of the bad smell. They saw the standing water, but they couldn't make the connection to understand that it was actually caused by a parasite, transported by mosquitoes. That wasn't there at that time, so just understanding the evolution of that. How public health systems had been in place going all the way back to ancient Egypt and just understanding that, where public health was at that time and understanding the scope of public health, how broad it is, so many different areas and how it's interdisciplinary. You have so many different disciplines coming together toward a common cause, from your epidemiologists to 00:30:00your biostatisticians to your behavioral science people to the nutritionists. It was just very broad and I was like wow, this is very interesting. Even to the medical people. That's when I was like well wait, after I took intro to public health, medicine seemed like just one component of this bigger system and I became more interested in the big picture. I was more interested in primary prevention. Then I saw medicine as well--medicine is necessary and important, but it only comes into effect in my opinion at that time once we fail to prevent heart disease. Now, medicine has to come in because you might have to do some kind of surgery for someone who has suffered a heart attack. So medicine is towards the tail end, so maybe we need to do more up front. I became very interested in that and because it was interdisciplinary I really liked that. I 00:31:00took more classes and then I said, you know what? I really like this public health stuff. I'm going to major in public health.

I declared my major in public health and then graduated with my bachelor of science in public health from Rutgers and then took a year off. I was applying to graduate schools, doing my web design stuff on the side, graphic design, and then went off and did my MPH [master of public health] at UNC [University of North Carolina] Chapel Hill within the Department of Health Behavior. While I was there, I was very, very lucky. First I had a fellowship, the [Hatch-Barnhill] fellowship, that not only provided me with tuition scholarship, but I also had the opportunity to be able to work as a research assistant with Dr. Eugenia Eng. Dr. Eugenia Eng, how can I say? She's very iconic in the public health world, especially in community-based participatory research, CBPR. She's 00:32:00one of those key researchers and practitioners in public health who's made enormous contributions in CBPR and integrating research with actual interventions and bridging the gap between research and practice.

For me, that was very interesting because I was interested in both; being able to do research, but also not just doing research for research's sake, understanding why you are doing the research, what you're trying to accomplish with the research. How does that impact lives in a meaningful, practical way, so it's not just numbers and figures and charts. It's about, this is what it means, this is what we need to do, and how do you come back to see if things have changed? That was very important for me and being able to understand that the work that we do has meaning, it's going to impact lives and it's not your typical research where you're so disconnected from the communities you're working with.

The project that I got to work on was called the Brother's Keeper project, 00:33:00looking at the issue of CVD, cardiovascular disease, among rural African American men in North Carolina. Cardiovascular disease is one of the leading causes of death in the United States, period. But there is a huge disparity in terms of African American men in the sense that while African American men, similar to white men or men of other races and ethnicities, get CVD at similar rates, African American men are more likely to die from CVD or have more long-term disability from cardiovascular disease. There is a huge disparity there and there are plenty, plenty of reasons for that if you take a broad look at it. The project was looking to work with the Black church. The Black church is very influential within the African American community. The idea was to work with the Black church as a proxy of reaching African American men to work with 00:34:00an existing structure, existing social support networks of African American men wherein you can have what we called "navigators." These are men within the church who would be trained to provide social support. These are lay health advisors that provide social support and advice to other men within the church where they were in terms of helping them to adhere to their cardiovascular disease care plan. Let's say if you have stroke or heart attack or something like that, you're given a care plan to say these are the medications you need to take. You need to exercise. You need to eat certain foods and avoid certain types of food. These are lifestyle decisions. If someone is used to eating their fried chicken for forty years and now you want them to be eating grilled chicken every single day, they might need some support in doing that to change these 00:35:00behaviors. Also, in terms of getting people to increase their level of physical activity. I mean, it's easier to just tell someone you need to exercise more, but it doesn't happen that way. We know that. Everyone knows they need to exercise more, especially if you have cardiovascular disease, but what people know and what people do, there's usually a huge gap. You need the supporting environment, the enabling environment, the reinforcing environment to make that happen. The idea is that with this intervention, by working through existing channels of social support--and then you get the men who serve as navigators. These are men that would already be respected and trusted by their peers and then they're able to--in a natural way, and that's the key, you're not disrupting, you're not creating anything new--in a natural way, they're able to provide that support to other men in the church to help them increase their level of physical activity, improve their nutritional intake and be better able 00:36:00to adhere to their cardiovascular disease care plan. Be able to check their blood pressure and all this kind of stuff. Go see their doctor when they are scheduled to go see their doctor. That was the whole idea.

I came in, I was involved throughout all phases of this. We had a lot of different participatory research approaches that we would take. For example, going to the church and doing participant observations. If I can step back, another aspect of what we did was working to incorporate health messages into the sermons. So, it was a bigger picture. It wasn't just working with these social support networks of men within the church, it was also engaging the pastors and the leadership within the church. You can have the pastor talking about the importance of these lifestyle choices in terms of what you eat and 00:37:00then using biblical scriptures to support these messages. That's what we did for two years. Going to these churches, doing participant observation where you're actually there. You're attending service. You're part of the audience. You have to be very natural. You can't be seen as you're there as a researcher. You're there to be there. But while you're there, you're also observing what is happening--almost every single thing that's happening. As soon as you leave, you get in your car, you start writing. You write every single thing that happened. The passages that might have been referenced, everything, essentially. It's very, very in-depth qualitative. To get a better understanding of what is happening within the church, what kind of messages have been given, the 00:38:00receptivity of these messages within the congregation, etcetera, etcetera. So we did that.

One of the things I was responsible for--two things. First, we were able to do several surveys with leadership within the church to be able to better understand their ability and what it would take to get faith-based institutions to engage in this type of work. Their readiness and their capacity. We did that assessment using validated instruments that were already in place. Then, in addition to that, I led the process evaluation of the trainings. As you can imagine, we had to do lots of trainings with these navigators, but we wanted to document the process to be able to see if the trainings went as planned--if there were deviations in the trainings, why those deviations were occurring. To just be able to see what exactly happened as part of these trainings and how 00:39:00they potentially could be tied later to the outcomes that we may see from the intervention. I got a really good experience between using quantitative methods as well as some of these qualitative methods. It's more of a mixed-methods approach. You're doing the research, but you're doing it with the community and you're engaging the community throughout every step of the process. As you're learning things, you're sharing these things with the communities that you are working with immediately. You're not waiting five years down the line to say hey, these are the things that are working in this community, these are the things that are not working.

In addition to that, just by working with Dr. Eugenia Eng, I was able to understand the importance of gaining trust of the communities you work with. That starts with how you gain entry into the community that you are going to work with, so that they see you as a partner and you see them as a partner and you see each other as equal partners. You're able to understand that communities 00:40:00have assets. They don't just have deficits because I think many times we see a lot of people in our field in public health and in other fields who have good intentions, but sometimes they tend to view communities as they have problems, they have deficits and we're going to come in and we're going to try to help these people. It's a completely different mindset when you're doing CBPR type of work using this type of lens that Dr. Eugenia Eng was using. She built on the work of many other renowned researchers in that field, in that department, especially in the health behavior department at UNC. Some of that work had been done in other places. Africa, where they started that work and then the two professors whose fellowship actually that I received, John [W.] Hatch and Dr. 00:41:00[Howard C.] Barnhill. They were key people in instituting CBPR and making a case for it. Now, a lot of people hear it, they accept it, but this actually--there was a huge case that had to be made for this. They did a lot of research to provide the data to support it and provide the framework to make this happen. Like I said, I was very fortunate and blessed to be in that position to be able to work with someone like Dr. Eugenia Eng. Not just in terms of the concrete skills that I gained from working with her that complemented my graduate studies, but it was also important because of the lens that it provided me to be able to view communities when doing public health work.

Q: That's great. I recognize that I've kept you speaking now for a good long time. Do you want to take a quick break?

JALLOH: No, it's okay. We can keep going. We haven't gotten to Ebola yet. There's a lot to talk about there.

Q: There's so much to talk about. In listening to you talk about the CBPR that 00:42:00you were doing in North Carolina, it's fascinating to hear the connections that I think probably came up with Ebola. But before we get to that, again--putting it off again--so what happens after grad school?

JALLOH: So, after grad school, I'll try to summarize these parts quickly because I know we have a lot to talk about in terms of Ebola. Actually, when I was at Carolina doing my MPH, I also got very interested in a certificate program they have in interdisciplinary health communication. This was kind of a new program that UNC had instituted. It was a partnership across the School of Public Health, the School of Journalism and the School of Library Sciences, the Department of Psychology, coming together to say, we need to look at all the resources we have here at the university. We have all these outstanding researchers who are doing similar type of work around communication and health 00:43:00issues. You have people doing state-of-the-art research around health behavior. You have professors in the School of Journalism who are doing state-of-the-art research around communication. You have state-of-the-art research being done in social psychology and all this kind of stuff and in library sciences. How do we pull it all together?

My cohort was kind of like the guinea pigs in a sense in terms of they were just starting this new--it was very interesting for me, it was exciting because I was able to get the opportunity to step out of the School of Public Health, to be able to take classes with people in the School of Journalism and be able to meet new professors there. It was a pretty good, structured, health communication certificate program that I really, really enjoyed. One of the best classes I took while I was there was a class looking at electronic media. Basically, when 00:44:00you take that class it's like a crash course in journalism. It's a graduate-level course. So, you are able to understand--how can I say, it's like from A to Z, but in one semester. It's linked with Carolina Week. Carolina Week is a student-run television studio at UNC, and they produced I believe two or three weekly programs that reach something like five million people in North Carolina. It's done very professionally. I've seen studios outside of the US, it's better than all of the studios I've seen in Sierra Leone for sure--better than all the ones in Guinea and many other places. It's really, really state-of-the-art production that's taking place there.

More importantly, you're actually getting the academic training to go along with 00:45:00it and you're able to apply that in a real type of setting. In this course, you're divided into teams. I had a team of like three other people that I worked with, it's a team of four. We had four medical news stories that we had to put together throughout the semester. You get to learn everything--the basics, at the very least, in terms of identifying a newsworthy story. After identifying a newsworthy story, identifying who the sources are that you're going to interview. In addition to that, all the technical things that go with that. We have to do our own interviews. We have to record it and videotape it and we have to shoot it professionally and we have to learn how to use the various equipment. You have to understand lighting. You have to understand a little bit of sound. You're not going to be an expert in any of these, you're just going to 00:46:00understand a little bit of it, just enough to make you dangerous. That's kind of like what happened and then we all took turns. If we're doing one piece, for example, I might get to be the producer and then someone else would lead in terms of videography. Someone else will lead in terms of sound. Someone will be in charge of lighting and then you, as a producer, will be responsible for writing up the script and everything like that and then shoot it. It's like a full production.

Again, it's not just something you're doing for fun. You're covering a real story. You're going to work with a real production team in Carolina Week. It's going to go out there and then people actually are going to see it. It was not theoretical. That experience again was really interesting. It was a good skill set to have to be able to understand--because a lot of times, people like us, when you're in public health, we're using all these fancy words and jargon and 00:47:00things like that and we're not able to communicate effectively with the public and the audiences. This was the first time we were challenged to take very complex health issues and be able to break it down, make it interesting and newsworthy for lay audiences. After doing that repeatedly, after each production you come back, we're able to critique it. Look at what worked, what didn't work and how it could be improved. That was a very, very good experience in addition to taking other health communication courses. In addition to my MPH, I was able to get the graduate certificate in interdisciplinary health communication, so I think that was also a great asset to have.

Then I left, and then as soon as I graduated, I had a job with RWJF New Connections. The Robert Wood Johnson Foundation had a national program called New Connections. The objective of that program was to increase the diversity of perspectives in forming the foundation's programming. They did that by 00:48:00increasing the pool of researchers that were working with the foundation--the researchers and evaluators. In public health, there's a school of thought that the person doing the research can be equally as important as the research itself because you, as the researcher, you bring your own perspectives, your lived experience, your worldview. When you talk about issues of health disparities, bringing that perspective of diversity is going to help shape and inform the research in a different way and a different angle because the questions you ask might be different and your life experience is going to shape the types of questions, research questions or evaluation questions that you're going to ask. I worked there for three years. It was a national program of RWJF. It was housed within a consulting firm, the OMG Center for Collaborative Learning in 00:49:00Philadelphia. I was there as a project coordinator.

It was a very interesting job because it allowed me to work across various domains. For example, we had to work with various teams within the foundation--the foundation had several teams and portfolios, so we had to work within these various foundation teams to understand their research needs. We were able to put together our annual call for proposals highlighting various priority areas from the foundation and then open it up to diverse researchers. In order to qualify for a New Connections grant, you had to meet at least one criteria in terms of your personal background in the sense that you had to be a junior or mid-career investigator that is either an ethnic or racial minority or first-generation college graduate, [whatever] your racial or ethnic background, or someone who grew up in a low-income household when you were young, [whatever] 00:50:00your racial or ethnic [background]. So, it was very diverse. You had African American researchers. You had Latina researchers. You had first-generation white researchers. It was a very, very diverse group of researchers that we were bringing together to do secondary data analysis for the foundation and also to do evaluation for foundation projects.

Q: Great, thanks for sharing that. After the Robert Wood Johnson Foundation, what happened then?

JALLOH: After New Connections--I was there for about three years, then my dad was at that time in Bangladesh with UNICEF. After he left New York, UNICEF New York, he was in Nigeria working with UNICEF. Then he left Nigeria and went to Bangladesh. After Bangladesh he was getting ready to retire in the end of 2011, so going into 2012. He said to me that, "I'm getting ready to retire. I would 00:51:00like to move back to Sierra Leone of course, but I don't want to go back and just be at home, just be a retired person." He said, "Because quite frankly," I'm just paraphrasing, "I'm retired, but I'm not tired," and he said, "I'm certainly not expired, so I should be doing something as opposed to just being there. With all this experience that I've had, I feel like I should be able to give back to the country and be able to help mentor young people in public health and be able to do some interesting type of work." I said, "I think it's a great idea." He told me, he said, "If you think it's a great idea then you should join me." I said, "How?" Then we started talking about it and then he had a lot of ideas.

First, we thought about doing maybe a consulting firm. He said, "A consulting firm is really not what I would want to do. I think I would prefer to do an NGO" [non-governmental organization]. And I said, "An NGO is going to be very involving." At that time, we had no experience in starting an NGO--no clue what 00:52:00that would take. So then I was like okay, well this is good. I kind of envisioned myself just supporting him from this side, from the US side, help him out with some stuff. Help write some proposals or whatever it was, so that's how we kind of started and then talked about the area we wanted to focus on. He said, "I'm very much passionate about issues of women and children. This is all I've done working with UNICEF for a long time." I said, "There are a lot of people working on issues of women and children in Sierra Leone. You have a lot of NGOs, so you have to think about what exactly within those issues that you are particularly interested in that you think the organization would have a specific niche in doing." He went back and thought about it and he came back and said, "There's a lot of evidence around the first one thousand days." The first one thousand days meaning from conception to when the child is two years old. They call it "the golden window of opportunity." Whatever gains you fail to 00:53:00accomplish within that period, many times you can't go back and fix it. Whatever quote-unquote "damages" that may happen during that period--for example, a lot of times you're not able to reverse things like stunting. You can't go back and reverse stunting. Or, if the mother is smoking or drinking a lot of alcohol while she's pregnant, that can have a lot of adverse effects on the child and those are effects many times that you are not able to reverse. Whatever good thing that happens during that period is very, very important for the child. Whatever bad things that happen during that period, you probably can't take back. As you can imagine, it is a very important period. Many times it's neglected, but it's such a critical period. By the time the child is two years old during this one thousand days period, the brain has almost fully developed, almost at ninety percent capacity, something like that, and cognitive functions, 00:54:00the child's emotions, lots of other psychosocial factors, psycho-cognitive factors. The science was very solid around the first one thousand days. No one in Sierra Leone was particularly looking at this period. So he said, "This is the area I think we should work in." Long story short, we came up with the name for the organization. We said, "Let's call it FOCUS 1000." All credit to him, he came up with that name. [laughs] I kind of helped and asked a lot of questions to help guide it, but he came up with the name to say FOCUS 1000. The FOCUS actually is an acronym and stands for Facilitating and Organizing Communities to Unite for Sustainable development. That's the FOCUS, and then the 1000 standing for the first one thousand days in the life of the child.

That's the birth of the NGO. It was really just an idea at that time. We had the 00:55:00name, we had some idea of what we wanted to work on, and I knew that it would to take more than just being in the US and helping out with this, so I said okay, I'm going to need about three months to transition out of my job and move back. So I did that. While I was doing that, he was working with other folks in-country because it's going to take more than just a father and a son team to build a strong, reputable organization. He reached out to a lot of other folks that he said were also retired but not expired yet, and said, hey, I have this idea, do you want to join? It was kind of like just very informal. It's kind of like a hobby. People that like this kind of public health work. So he was able to pull together a very strong team.

He reached out to Dr. [Samuel] Abu Pratt. Dr. Pratt had been like a veteran ,one of these very respected district medical officers in Sierra Leone. He had worked in some of the most difficult districts in Sierra Leone--Koinadugu, Port Loko, 00:56:00Kono. No one wants to work in these areas many times. He worked in these three areas. When you're a

district medical officer in Sierra Leone, you're essentially the pediatrician. You are the OB-GYN [obstetrician-gynecologist]. You are the surgeon. You do everything, everything in addition to doing all the other administrative work because you're overseeing the district health; the DHMT, the District Health Medical Team. You have a team of nurses and everyone else who is working underneath you, so you have all those administrative tasks in addition to all these other clinical tasks that you have to be responsible for. You can imagine, Dr. Pratt was someone that would be ideal, great to have. He said, "Yes, this is great. I'm retired also." Dr. Pratt also worked in UNICEF for like ten, fifteen years after he left Ministry of Health [and Sanitation]. So got him. Then, reached out to Paul [A.] Sengeh. Paul Sengeh is a biostatistician and probably 00:57:00one of the best in Sierra Leone. He had also worked in government for a while. He had also worked with UNICEF as a monitoring and evaluation specialist for many, many years. Well respected. Paul Sengeh said, "Sure, sounds like a good idea," and then reached out to George Saquee. George Saquee, he's an environmental engineer and he had worked on water, sanitation and hygiene issues for many, many years, so he got pulled in. Then also I reached out to Melrose Tucker. She was a nutritionist, also worked with WFP [World Food Programme], worked with UNICEF, worked with Ministry. So she got pulled in, and many, many, many other people. They all said, we're going to build a reputable organization. We have to create an actual board. A lot of times in places like Sierra Leone, people don't pay attention to "let's have a strong board of directors" and 00:58:00that's usually a mistake. They said, let's have a meaningful board of directors. This is almost like a movement that we're doing. Let's create a national NGO that's reputable, that's going to have people with the skills, experiences and knowledge to make this successful. So they reached out to so many different people. They pulled together a very vibrant board of directors and had influential religious leaders on the board of directors. Had people who had been in government but retired. People who had ministerial positions, former ministers were pulled into the board of directors. That's something that I didn't do any of. I was just here, I supported, but they did all of that in-country.

Eventually, I went back, December 2012, and joined the FOCUS 1000 team. To make it short, those first few years we spent a lot of time developing our strategic 00:59:00areas. The regular things when you build a reputable organization: putting systems in place, financial systems, financial controls, administrative systems, HR [human resources] systems, IT [information technology] systems. It goes on and on and on. You're doing all of this without any kind of funding. We were all self-funding. Everyone is just scraping whatever they have here. You have a little bit of savings here? Okay, great. You can buy this table, you can buy this computer. That's kind of how it all got started, but we needed to hire other people. So then we said okay, fine. We'll bring people on. We'll tell them what our goals are. If they buy into the idea, they can work. We pay them when we can pay them. When we can't pay them, they work as volunteers. If that works for you, great, if it doesn't work, sorry. That was the mentality because everyone was there to give back. Everyone was there to just contribute. That was the founding of FOCUS 1000 and that's how we got started.

Then, we started putting together very solid proposals and bidding competitively 01:00:00for projects. We won several awards, big awards. Our first award was from DFID, the UK [United Kingdom] Department for International Development, around packaged water. People said, what the hell does that have to do with the first one thousand days? We said well, it does have things to do with the first one thousand days because issues of water and access to water and water quality, water safety is a big issue in the developing world. In Sierra Leone, it's a very, very big issue because more than fifty percent of the population do not have access to safe water, which is a serious problem. As you can imagine, diarrheal diseases are a leading cause of death. We saw a clear connection between packaged water and the health of children because of the link with diarrheal diseases. It was a huge undertaking because we had to work with 01:01:00several government ministries and departments and agencies to assess the packaged water industry, to develop comprehensive regulations for the packaged water industry, to train government ministries and departments on how to be able to enforce these regulations to build their capacity to do that and then also, to train packaged water producers to be able to meet these regulations. Then, sensitize and educate the public about all of that. That was our first project. Since then, we were able to get several other projects, blah, blah, blah.

Q: Can you just very briefly describe what a few of those projects were?

JALLOH: FOCUS 1000, we had a very unique approach in the sense that we almost worked as a consulting firm and at the same time as an NGO. So there was some projects that we would do--let me step back for a second in terms of our 01:02:00priority areas. We always had a strong belief that whatever we do must be driven by evidence, robust evidence. Our inventions have to be evidence-based and we have to be able to evaluate our programs to be able to know if they work, when they work, who they're working for, why they work. All this kind of stuff, we wanted it to be able to know. We didn't want to just start developing programs and doing things and just be all over the place. So we said, evidence must be at the center of everything that we do. Another principle was that we have to engage the communities that we work with. Everything we do must be led and owned by communities. Again, you can start to see some of the connections between some of that CBPR work in rural North Carolina working with Black churches. Now, in Sierra Leone. it was very interesting because it's a different context, but 01:03:00nonetheless, the issues are pretty much the same and if you apply these principles they are pretty much cross-cutting across cultures and geographic settings. It really doesn't matter. These are fundamental principles that we believe that we should embed and incorporate into our programs.

Similar to the thinking from Dr. Eugenia Eng, we believe that we should not be doing things that don't have any meaning or impact. The needs are real and the issues are real. People's lives are sometimes at risk. You have women who do not have access to safe clinics in Sierra Leone. There are lots and lots of issues we wanted to focus on, but you need to be able to be strategic. First, you need the evidence. Once you have the evidence, you need to be able to take that evidence and make sense out of it. Sometimes you need to advocate. You need to be able to advocate with government to get their commitment. You need to be able 01:04:00to engage communities, stakeholders, diverse community stakeholders.

We were applying all of these principles in a very practical way. I'll give you some quick examples. One of the early project also that we got was to work with civil society to scale up nutrition in Sierra Leone under the SUN--Scaling Up Nutrition. Also, a project funded through GAVI [Global Alliance for Vaccines and Immunization], through the GAVI Civil Society Alliance. Then we wanted to be able to improve immunization coverage in Sierra Leone by working with civil society groups. Essentially, FOCUS 1000 became the facilitating organization for these two civil society platforms. We put it together, set up national task forces, be able to identify concretely the indicators that we wanted to measure our success through and then build a very, very vibrant, robust network of civil 01:05:00society organizations in Sierra Leone--diverse civil society organizations. Your faith-based organizations, your small community-based CBOs, some other NGOs working in nutrition and immunization. We pulled them together and now they have what they call SUNI--Scaling Up Nutrition and Immunization platform in Sierra Leone. Working in partnership with government, working in partnership with the business sector, the private sector. And then more importantly, getting these community representatives to be fully engaged in issues of women and children, especially around nutrition, which we know is usually the underlying cause of under-five death in Sierra Leone, and then immunization. There are lots and lots of diseases we can prevent by immunization. Things like polio, measles. We knew 01:06:00that these were key areas and you would need broad-based civil society support in order to turn this around into meaningful results.

That's what we've been doing now. We've set up, back when I was there we were able to set up district coordinating bodies, what they call the DCBs, in Sierra Leone in all fourteen districts. It's functional right now. They are using radio. They use mixed channels in how they deliver interventions. Radio, sometimes community-level efforts, outreach, etcetera, etcetera. And many times also advocating and partnering with government and other entities outside of government as well.

Q: FOCUS 1000 is really doing a lot over like several different spheres like advocacy and being practical, bringing civil society together. Did you have a defined role within the organization or were you jumping between things?

JALLOH: I was all over the place. We had a small team and everyone was all over the place. That was one aspect of the organization that was quite different from other NGOs or other organizations in general. It was a very flat organization. Our CEO [chief executive officer] would sit there and help analyze some qualitative data. Our CEO would write letters. Everyone was doing almost everything, but as time went on and the organization grew and then we had departments and things like that, I was a senior program manager and I was responsible for several things, but one of the main things I was responsible for was leading our applied research, monitoring and evaluation efforts. That was really my focus area and making sure that the evidence we're generating are being infused in our programs, and also I'm helping to evaluate programs for 01:08:00other partners for UN [United Nations] agencies. Evaluate programs for UNICEF. We are evaluating programs for UNFPA [United Nations Population Fund], to be able to say okay, these programs are working. They are working here. They are not working here. So that was a big part of what we did those first few years, and then Ebola hit.

[break]

Q: We're back. As you said, Mohamed, and then Ebola hit. Take us from there.

JALLOH: Okay. Sierra Leone had its first case of Ebola in May 2014. Before then, Guinea had its own first case--really the first case started December 2013 in Guinea, but by the time it got recognized it was early 2014. I remember when the Ministry of Health had the first call in Sierra Leone to just give some quick updates that there are now cases of Ebola in Guinea, I was actually at that 01:09:00meeting. They just kind of described it, the symptoms they were seeing, and they believed that this was a case of Ebola. Not long after, they were able to confirm that actually Guinea had an Ebola case.

I was like, what is Ebola? [laughs] I had read about it when I was doing my undergraduate studies actually, in terms of the links with bioterrorism as one of the potential diseases--viruses that could be used as a bioterrorist agent. Outside of that, I didn't know much about Ebola myself and a lot of people, no one knew what Ebola was in Sierra Leone--I mean in the general population. It was very new, and very quickly after it hit Guinea--at that time I was out in Port Loko doing some research. Applied research. We were out doing some data collection. I remember a lot of people were very panicked and were asking me 01:10:00questions. I didn't know much about it. They thought because I'm in public health I may know stuff. A lot of these images started coming out even before Ebola hit Sierra Leone to show--the only way people could learn is by going on the internet. They went on the internet and a lot of the images they were able to find were images of blood coming out of people, like their eyes, their ears. These very, very graphic, fear-based type of images, and that was the message that was out. Everyone was scared. Like I was saying before, it's kind of like the links with war. There were a lot of uncertainties around. Is it going to come to Sierra Leone? If it does come to Sierra Leone, what is that going to mean for us? No one knew, no one could answer and people were worried. Are we going to be able to handle something like Ebola? It looks very scary. It looks very fearful, so people were very nervous.

That was the background. When Ebola finally hit Sierra Leone in May, I was actually in the US, here for the summer. I was visiting family. I was here until the end of June; beginning of July, I went back. When I went back, at that time, Ebola was still in the eastern part of Sierra Leone. As I mentioned, this was a really similar area to where the war entered Sierra Leone from Liberia. That area is really--it shares a border between Liberia, Sierra Leone and Guinea. The culture there is very, very similar. You have the Kissi people and some other ethnic tribes. They're all kind of--I don't want to say related, but just to give an example, there are some families in that area that actually have relatives in all three countries, because maybe you're twenty--less than twenty 01:12:00miles out, you're in Guinea. Less than five miles out you're in Liberia. Less than two miles, you're in Sierra Leone. It's all kind of connected. When that happened at that time when I moved back, there were some messages you would see saying that Ebola is real. That was essentially the only campaign that was out at the time. Ebola is real, Ebola is real. You heard it on the radio. There were lots and lots of conversations. People were very scared.

Kailahun was the first-hit district in Sierra Leone, and then we started seeing a lot of cases. It was restricted to one chiefdom, then it became two chiefdoms, then several more chiefdoms, and then we started seeing more cases in Kenema because Kenema is next to Kailahun. The Lassa fever lab [laboratory] and 01:13:00facility in Kenema, that's where they were treating people with Ebola at that time, or suspected cases. We didn't know a lot about Ebola as a country, so that was very, very challenging. The best we had was the Lassa fever lab because it's also a hemorrhagic fever, Lassa fever, and had a lot of similarities with Ebola, so we were kind of fortunate in that sense that at least that facility was there. Unfortunately, that facility didn't have the infrastructure needed to be able to address Ebola, especially at the scale that we were seeing cases. Lassa fever we might get one case, two cases every now and then. Now we were seeing a rapid spread of Ebola from Kailahun to Kenema. It was contained in these two districts for a little while, for these first few months. When I went back to Sierra Leone in early July from the US, the cases were mainly in Kailahun and Kenema, in the eastern part of Sierra Leone. At that time, there was really no 01:14:00clear, coordinated plan on how to address Ebola. There were lots and lots and lots of moving parts. Lots of meetings, but the outcome was very much unclear. I sat in many, many meetings at that time when Ebola first hit. People were talking about what needs to be done, what's happening, no one really knew. It was a period of confusion. Lots of commitment, I'll tell you that. A lot of people were committed. People showed up, they went to these meetings, but we didn't see much happening coming out of it.

Very quickly after Ebola hit Kailahun and Kenema--quickly we started seeing cases in the capital city in Western Area, and then from Western Area we started seeing cases in Port Loko. Port Loko quickly emerged as the second epicenter. So it was Kailahun and then Kenema kind of, but then Port Loko. We started seeing a 01:15:00lot of cases in Port Loko, and because Port Loko is very close to Western Area, we started seeing a lot of cases in Western Area. So you're seeing cases moving from Port Loko to Western Area, Western Area to Port Loko. Other districts started getting one case here, one case there.

FOCUS 1000 at that time didn't really have a formal role in the response. Again, there are not a lot of defined, formal roles, but one thing that was defined very early on in Sierra Leone was putting together the pillar structure. You had several, several pillars. You had the case management pillar, you had the burial pillar, you had the psychosocial pillar. You had what they called the social mobilization pillar and communication. That pillar, the name changed after a while, but really that was the pillar where we saw ourselves having a role, meaning FOCUS 1000 and a lot of other folks who were working with communities.

I said to the FOCUS 1000 team, I said hey, we need to be engaged. We need to be 01:16:00involved. They said, how do we get involved? I said we need to be involved at the pillar level, they said perfect. You should start attending the pillar meetings.

Q: So who was holding pillar meetings and how did this pillar idea get defined?

JALLOH: The pillar structure was put in place by the government, but of course, with the advice of other partners, the UN partners at that time primarily. You would have a government ministry, mainly Ministry of Health. Let's say for example, the social mobilization pillar was headed by the health education division with the Ministry of Health and then co-chaired by UNICEF. That's how the pillars were set up. Then take for example the surveillance pillar. That one was headed by the directorate of disease surveillance in Sierra Leone in 01:17:00addition to UNFPA, as the UN body co-chairing that pillar. That's how it was, a government ministry or a department and a UN partner leading these pillars. Like I said, at this time, the country had two ambulances--the entire country. Two, that's all. The messages were not clear and then--

Q: So you start attending the pillar meetings?

JALLOH: Yes, I started attending the pillar meetings. One of the first challenges we had was that we have to come up with messages to be able to educate the public about what Ebola is, what the risks were and things like that. I didn't know a lot about Ebola, so I decided I should just learn some more things about Ebola. I went on the internet and was able to read a lot of background materials in terms of first clinical signs and symptoms of Ebola, modes of transmission, blah blah blah, prevention methods--be able to read up on 01:18:00Ebola outbreaks in places like Uganda, the DRC [Democratic Republic of Congo], to really understand the history of Ebola. I was like well wait a minute, Ebola is kind of old. Ebola's been around since the seventies. Ebola's like over forty years old right now, but we are so confused as to what to do. I'm like, why aren't we learning more from places like DRC? Places like Uganda? Their situation was completely different from what we're seeing in Sierra Leone because of how widespread the outbreak was, but nonetheless, they've dealt with Ebola before.

In DRC, places like Uganda, usually what happened, you would get one or two cases in a small cluster and then those would probably spread out to a few more cases and sometimes would get up to maybe a hundred cases, few hundred cases at the most. That was the extent of Ebola. Sometimes between fifty to sixty percent 01:19:00of people would probably die and then others may survive, but beyond that not much was known in terms of how to handle this type of outbreak in urban settings. In the past it has been in rural settings and pretty much contained there for a while. You didn't see a lot of movements with people going from one place to another. As Sierra Leone was developing slowly now, the road networks had been dramatically improved, so now we had an improved road network in Sierra Leone, which meant that people were easily able to move from places like Kailahun and come to Freetown in a matter of just six or seven hours. In the past, that'll take a whole day, so people would not move as much. Again, this is where advancement within a country can also become a problem down the line in terms of public health, which they're almost at odds.

Anyways, I started attending the pillar meetings, and the structure of these meetings, basically--it was daily, first of all. It was very, very intense, 01:20:00daily, eight o' clock in the morning. Again, everyone was committed. Everyone was concerned. There were lots of uncertainties. We will show up and then we'll get a lot of updates about what's happening, state of the epidemic. How many districts have gotten cases, the details of those cases, transmission patterns. And then some thinking and planning around what should be done, but it really wasn't organized, to be honest. We have to be honest about that. We said, you know what? We have to get a little bit more organized. I remember early August we decided to come up with these sub-committees within the social mobilization pillar. We said okay, let's have a coordination and M-and-E [monitoring and evaluation] sub-committee. Let's have a sub-committee on messaging. Let's have a sub-committee on capacity building and training. The meetings were just too large. One hundred people in a meeting. How much can you get done with one hundred people? Everyone just talking and talking and talking, nothing was 01:21:00getting done really. People with good intentions sometimes talking about things they really don't have correct knowledge to speak on.

I'll tell you some of the issues I saw from the very beginning. From my limited reading on the internet, just reading some peer-reviewed publications on the past on Ebola, etcetera, etcetera, I saw a huge disconnect. Already we had several hundred cases in Sierra Leone, yet the focus was still on animal-to-human transmission. That was a big mistake. It was very clear from the literature--of course, Ebola is a zoonotic disease in the sense that it transfers from animal to human, but you only see that in the very beginning when you're getting the first case. After you've had maybe one or maybe two animal-to-human transmissions, then you're going to see mostly human-to-human 01:22:00transmission. Therefore, the focus of the messages from early on should have been on how do we prevent human-to-human transmission. A lot of the messages at that time that the Ministry and all these partners were putting out focused on telling people to avoid bush meat, to avoid bats and monkeys and to avoid fruits that had been bitten potentially by bats. I remember one time I was out, I was eating some meat and someone came up to me, "Hey, is that bush meat? You shouldn't be eating meat right now." I said "Actually, I don't think I'm at risk by eating just normal meat that was cooked." But again, it was a signal of the disconnect, and the message actually was resonating with the population because everyone was focused on animal-to-human transmission--scared of getting Ebola from bush meat or from touching some kind of wild animal. Nonetheless, they'll go home and take care of a sick family member that's exhibiting signs and 01:23:00symptoms that are similar to malaria. They might think oh, it's malaria, so let's take care of the sick family member. People were still attending funerals and burials and washing the corpse of their loved ones, but yet the epidemiological data told us that these were the high-risk environments. Those were the high-risk behaviors, but the messages were not addressing these. There was a huge disconnect. People like myself--and there were several other people who were saying, we have to start doing things a little differently. We need to infuse more science into this Ebola response, especially in terms of social mobilization. The messages we're putting out and then the interventions that we're putting out. Most of the interventions during this period leading up to August--people holding megaphones, walking around saying hey, Ebola is here. Ebola is real. If you get Ebola you're going to die. There's a good chance you're going to die. So there was lots of fear messages that were going out. 01:24:00That was the extent of the educational campaign at that time.

The idea was that we had to move away from that. FOCUS 1000, even before Ebola hit Sierra Leone we had said we needed to do a KAP survey. KAP standing for Knowledge, Attitudes and Practices. Usually, learning from HIV/AIDS [human immunodeficiency virus/acquired immune deficiency syndrome] in Africa, these surveys, these are nothing new. There had been standard frameworks for doing KAP surveys for HIV/AIDS to understand knowledge, attitudes and practices. The reason why a KAP survey is important is because whenever you're talking about trying to change behaviors, you have to do that by understanding the baseline, in terms of where the population is you're intervening with. In this situation, the entire country really. We have to be able to understand the level of 01:25:00knowledge in terms of Ebola modes of transmission, signs and symptoms and that kind of stuff and how to prevent. We need to know what people knew. We need to be able to know how people were perceiving, understanding and believing different things surrounding Ebola. Perhaps more importantly, we needed to know what people were doing to try and prevent or what they were intending to do to try and prevent or if they were sick, what would they do if they were sick or someone else in their family was sick. A whole host of issues that we needed to understand. We had no information about that. Therefore, our messages were not targeted to the needs in terms of the high-risk environment and the high-risk behaviors and there was a huge mismatch.

FOCUS 1000, this was actually even before Ebola hit Sierra Leone, had said, let's do a KAP survey. But as a small NGO at that time, we didn't have the resources to do it by ourselves, so we had reached out to some partners. There 01:26:00was some interest, but then once Ebola actually hit, we were literally told that we've been overtaken by events. That was the message that a KAP survey--this is not the time to be doing research, even applied research at this time. We should be focusing on what kind of messages we can put out. It was just kind of like, let's put messages out, but not even thinking about well, what kind of messages do we need to put out? Who do we need to target with these messages? Are the messages going to be sufficient? Because messages are just one component, but in public health you have to think about the enabling environment for these messages. Your reinforcing environment for these messages. You have to think about who would be the right messengers for these messages. What channels are you going to use to deliver these messages? Who are going to be the trusted sources to deliver these messages? None of that was being discussed.

Q: Where were you getting this message? Sorry to use that word--that you really 01:27:00just needed to get out there and give a message?

JALLOH: From people in leadership. From people in leadership within the country at that time, whether it was in government or within the UN agencies, because these were the people that were leading the response. We didn't get a lot of support initially when we said we need to do the KAP. There was some support, but once Ebola hit, things became kind of disarrayed and people were not seeing this as a priority anymore because maybe in their minds they saw it as another academic activity. But the way we looked at it, this was not going to be an academic activity. This was going to be something that's going to help generate some baseline understanding of where things are in terms of where the population was in their thinking, in terms of their knowledge, their attitudes, their beliefs and their practices. Eventually, to cut through a lot of that, we were able to get sufficient support in the sense that people said, if you want to do it, you can do it. We said you know what, we have the expertise to do it, meaning FOCUS 1000. We have the human resources and we have the knowhow, so 01:28:00we're just going to do it.

I was tasked with leading that, so I started developing the instrument. A lot of what I did at that time was looking at the HIV/AIDS KAP surveys to see validated items that were used in the past. Look at some of the M-and-E frameworks that had been used to roll out similar types of surveys in the past, looking at the science in terms of Ebola transmission to be able to see, what are the areas we need to focus on in the survey? Because when you're doing a survey you can ask all kinds of questions, but are you asking the right questions? I wanted to make sure that we were going to be asking the right questions. So, we developed a draft instrument. We developed a protocol for this. These are all standard procedures, and we had been doing other surveys in Sierra Leone. Fortunately, we had done similar national surveys evaluating UNFPA programs, UNICEF programs, 01:29:00programs [unclear]. We had a team of people we had trained in the past to do this kind of robust, high quality data collection. We knew we had what was necessary to get it done. We didn't have the money to do it, but we said you know what, money is not necessarily needed because we have a lot of what we need.

We got the ball rolling and then we started reaching out to more partners. I reached out to a friend and a colleague who was over at CRS [Catholic Relief Services], Meredith Dyson. I said, "Hey, we want to really prioritize getting this KAP survey done. Can you provide some support?" She said, "Yes, I totally agree we need a KAP." So she came on board. She got CRS on board. CRS committed five thousand dollars. Then we were in a meeting--one of those social mobilization pillar meetings--and they were thinking about doing a house-to-house campaign. The first House-to-House Campaign, whereby they would go out and give information about Ebola and then do some active case searches 01:30:00and then give out soap or something like that. It was being planned. This was the first time the House-to-House Campaign was being planned and it was being modeled off of other outreach campaigns for Maternal and Child Health Week, which usually is an ongoing campaign in Sierra Leone. They do it at least once or twice a year, so it was a similar model using twenty thousand volunteers to cover the entire country.

For me, I was very concerned because I'm like, wait a minute, I saw the budget. It was going to cost over 1.5 or close to 2 million dollars. I said okay, it's a national intervention and it's two million dollars, but I'm not sure if we're going to get anything out of it and there's really no science behind it. In the meeting, I got up and I said, "I think this is a good effort. Maybe we should do it, but if we're going to do it, we need to understand why we're doing this. 01:31:00What are our objectives? How do we measure success? If we do it, how do we come back and say it was successful?" For me I said, "We need to be able to improve people's knowledge about Ebola and we need to be able to influence how they are thinking about Ebola. We need to be able to improve and change some practices. Specifically, we need to be able to shift practices around burials--meaning that if someone dies, we did not want to see people having any kind of physical contact with the dead body. We also wanted to make sure that people would seek care if they had signs and symptoms of Ebola. That would be how we would measure success in my opinion, but none of that was happening. When I said that, the representative from UNICEF, the head of UNICEF at the time, he also has an 01:32:00M-and-E background. He said, "You know what, you're right." He said, "We should definitely do something, we should be able to establish a baseline like you've said and UNICEF will support that." So he came in and he was very, very supportive.

Fortunately for us, even though it was kind of delayed when they came in. When he came in, he added a lot of value, [Pierre] Rollin, he was the representative of UNICEF at that time. He had been responsible for a lot of M-and-E work within UNICEF around HIV/AIDS. He also had a lot of background knowledge, had a lot of materials on HIV/AIDS KAP surveys. He had actually done HIV as KAP survey for UNICEF, so he was a really, really strong ally to bring in at that time. We worked closely together me and him and other people from FOCUS 1000. We finalized our instruments, our protocols. We agreed on the districts where we were going to go. We went out, we implemented it within a matter of one week. We 01:33:00finished all the data collection. We got the data, we did all of our data entry, double-entry verifications. We took that data into SPSS, we analyzed it and in a matter of just two, three days, we said you know what, we don't need to worry about coming up with a big fancy report. We need to immediately highlight key findings around knowledge, key findings around misconceptions--attitudes, intentions, beliefs, practices. So we looked at all the findings and picked the most relevant ones that we knew we can intervene around.

Immediately, we saw that already everyone we interviewed had heard of Ebola, everyone. 97% believed that Ebola existed in Sierra Leone, so there was no need to convince people Ebola is real. People knew it was there. They already believe, so we were delayed in terms of our message and we should be focusing on other things. People wanted more information about Ebola. More concrete 01:34:00information in terms of how to prevent and how to treat Ebola. That's what people wanted to know. That was the information that they wanted and we saw that there were lots of misconceptions. So knowledge was high. People knew, yes, you should avoid contact with bodily fluids. You should avoid burials, but there were lots of misconceptions. One, people believed that Ebola can be transmitted through mosquito bites. Maybe Zika, but definitely not Ebola [laughs]. People believed that Ebola was airborne. Definitely, Ebola is not airborne. People believed that spiritual healers, traditional healers can treat Ebola. We know that's not the case, they cannot treat Ebola successfully. People believed that if you washed with salt and hot water, which was a very popular myth and misconception that became widespread through social media.

Supposedly, some pastor that was well respected in Nigeria, sent out this 01:35:00message that if you wake up at 3:00 am and you wash with salt and hot water, you would prevent yourself from Ebola forever. That message became very popular, spread through WhatsApp, which is a very popular application in Sierra Leone among young people. Once they got the message, they passed it on to their family members. This pastor eventually said, "I didn't say that." Someone made that up and said the pastor said that. They used his name, the fact that people trusted him and he was popular, to come up with this. No one knew where it exactly came from. Next thing you know, the entire country people are waking up. I got a call at 3:00 am telling me you need to wake up and wash with salt and hot water so you can prevent Ebola. I was so confused by that. My mom called me. She said look, I know you're a public health guy. I know you're not going to believe 01:36:00this. I don't really believe it either, but it's not going to hurt to just get up and to just do it. So I said, just to make her happy I said okay, I'll do it and then I went back to sleep. She told my dad the same thing. My dad laughed at it. She actually tricked my dad because she went and put salt in hot water. Because you don't always have running water. That day, unfortunately, my dad--the tap was not running, so he had to get water from the bucket and take a shower in the morning. But what he didn't know is that my mom had went and put some salt in the water to help prevent my dad from getting Ebola. He didn't know that. Eventually, he found out and we all laughed about it. But it just goes to show how popular that message was. People believed it. It was 3:00 am I heard neighbors and everyone just getting up and trying to take this shower. To show the power of misconceptions and messages when they come from a trusted source and they use a channel that's very popular. WhatsApp, it spreads out and people 01:37:00believe it.

After we did the first KAP survey at FOCUS 1000, we used these findings immediately to present it to the then-EOC. At that time the emergency operations center was housed in WHO [World Health Organization]. It was a makeshift EOC. Very small EOC, and the 117 call center had been put in place. It was also housed within the EOC at that time. That was also like a makeshift, 117 emergency call center. The number had been there, but it was never used in the past, so once Ebola hit, they activated it. They were trying to promote getting people to call 117, but it was challenging. You only have two ambulances in the country and you have millions of people and then you can potentially have thousands of calls coming in. How are you going to respond to that? They were not able to respond to these calls. It was very, very challenging. You had a weak health infrastructure, health delivery infrastructure that was not able to 01:38:00meet the high demand that we were promoting at the time.

To summarize, we did KAP One--the first KAP survey, I think in my opinion it was groundbreaking in many terms, in the sense that this was the first time a KAP survey was being done [in the] middle of an outbreak and the data was being used to inform the outbreak itself. So we took the findings to the EOC, we presented it, we were able to identify concrete areas to say look, we need to move beyond "Ebola is real." We need to get into a new phase where we're able to highlight high-risk environments, i.e., burials and funerals. Places where there are sick people at home, these are high-risk environments. We need to communicate that. We need to let people know that you get Ebola more than likely from someone who's close to you; a family member, a friend; not necessarily from bats and monkeys. Your chances from bats and monkeys, very low. Your chances from a 01:39:00family member who you think might be suffering from malaria can actually turn out to be an Ebola case--you're going to probably take care of that person. If that person dies at home, you're going to wash the dead body. We need to educate people about this. It has to go beyond giving messages also, we knew that. We need to engage the religious leaders. So immediately, FOCUS 1000 saw the need to engage religious leaders and that became our next area of an intervention working through the Social Mobilization Action Consortium.

I don't know if you have any questions at this time or if you want me to just keep going.

Q: Keep going.

JALLOH: After we did the KAP One survey, that was right around the time when CDC was coming in country in August. The first CDC health promotion team at that time, led by Vance [R.] Brown. They came in, they saw the KAP survey, and CDC said you know what, we need to do more of this. In early September, when we had just released the findings from the KAP One survey, we were very fortunate to 01:40:00have a high-level senior person from CDC that was in country, Dr. [Jonathan H.] Mermin, who's heading the Center for HIV/AIDS here at CDC, he's the center director. He was there, high level. He was the response lead for Sierra Leone at that time and Vance Brown was the health promotion team lead working under Dr. Mermin. They saw tremendous value in what the KAP survey had provided and they were very excited about that and said, we need to do more of this. Other people thought we didn't need a KAP survey anymore because we had a baseline. This is all we needed and we need to wait six more months. Dr. Mermin said, no, we need to do this every month. Unfortunately, we couldn't do it every month, but we ended up doing it every two months.

Something else he asked was--I remember he called me into a meeting and said, "Mohamed, this is great work. You have our support. What do you need?" I said, "We need a little bit more funding so that we're able to hire more people to get 01:41:00this done and do it right." He said, "What else do you need?" I said, "If we can move away from paper-based data collection to digital data collection, that will reduce the time it takes for us to get the data back and for us to turn that data into something that we can use." He said "Okay, no problem." He assigned Ray [Raymond L.] Ransom to the project. Ray Ransom had been managing a lot of informatics for CDC and fortunately, he was also in-country at that time. So we worked together and we digitized the KAP survey and we started doing the surveys using tablets, Samsung tablets. So, Ray Ransom worked with me. He helped train me on how to develop the surveys in ODK, Open Data Kit. So we moved all of the KAP operations to the ODK platform and then we did the second KAP survey in October, 2014. Just two months after we had completed the first one, we completed the second one. So, it was on a two-month cycle for the first three surveys. The first in August, the second in October, the third in December. Each 01:42:00time, we saw very interesting findings.

After KAP One, something else that was done that I think is really important for us to capture was that CDC was coming in country and CDC said, we need to have a comprehensive messaging guide. Nick [Nickolas M.] DeLuca, who also was working with Dr. [Jonathan H. "Jono"] Mermin here in Atlanta, he was in-country. He has a very strong background in communication. He said, "We can learn from what we've done in terms of HIV/AIDS in the US." So he said, "Let's come up with Act Against Ebola. Similar to Act Against AIDS here in the US." We said, "Fantastic," so we used the KAP data to inform Act Against Ebola, which was a comprehensive messaging guide that prioritizes high-risk environments and high-risk behaviors and concrete, simple-to-understand messages. For a long time 01:43:00for example, when they talked about bodily fluids, no one knows what bodily fluids are from a layman's perspective. You can be very specific to say, blood, saliva, etcetera, etcetera. The comprehensive messaging guides were more specific--gave simple, easy to understand messages that we can develop programs around. Radio programs, community engagement programs, etcetera, etcetera.

In addition to that, we also developed--FOCUS 1000, working in collaboration with CDC, UNICEF and other partners--a social mobilization community engagement strategy. An actual, laid-out strategy looking at, who's our primary audience? Who's our secondary audience? What channels should we be using? Who are the influencers? Who are the trusted sources? We were able to draw from the KAP data to answer a lot of these questions. Where do we need to focus our efforts? Unfortunately, right after KAP One, we needed to focus our efforts everywhere 01:44:00because it was so widespread and the misconceptions were everywhere. But we saw that there were some geographical locations where we saw higher levels of misconceptions. So we knew that we needed to intensify efforts in these areas. We did a lot of that and then we created the framework to continue to measure changes in knowledge, attitudes and practices. Then, we did KAP Two with the digital instruments. After we completed KAP Two, we saw that a really, really high proportion of respondents said, if a loved one were to die, they would not accept a burial that does not involve the touching or washing of the dead body. Meaning that people still wanted to continue to touch, wash the dead body as they've been told to do in the past.

We saw an even greater need at that point to engage religious leaders. That is where FOCUS 1000 then pulled together a national task force of the most prominent and influential religious leaders in Sierra Leone. We revitalized the 01:45:00Islamic Action Group and the Christian Action Group. For me and for many others, drawing back from my experience working in rural North Carolina with the Black church, that experience came in very, very handy. We said we need to task these influential religious leaders for them to go back and look into the Bible. Go back, look into the Quran. Identify supporting evidence in these books for these key messages in terms of--so we had Act Against Ebola, but these were like scientific messages. We have to put a religious spin to it, so that when imams are going out there now or our pastors are going out telling people don't touch or wash dead bodies, they have evidence from their respective books to support those messages. Because for the past many, many, many years, they've been preaching these messages to say you need to touch, you need to wash the dead body. Now, they're going to go against what they've been preaching for God knows 01:46:00how many years. It was going to take evidence to do that. Not necessarily just the scientific evidence, but messages from the Bible and Quran that are going to resonate with someone who is Muslim, someone who's Christian. In Sierra Leone, ninety-five percent of the population is either Muslim or Christian.

We knew this was a key group, and they did a very, very thorough, diligent, diligent job of documenting and identifying strong evidence from the Quran and the Bible to support these messages around burials, around medical care, around avoiding stigmatization of Ebola survivors. It was quite powerful. They put that into a manual. They developed what they called "prototype sermons." If an imam wanted to talk about safe burials, they had some key messages that those imams should be delivering. Then they went out and trained. We supported them, FOCUS 1000, through the SMAC consortium, the Social Mobilization Action Consortium, to 01:47:00do that work. To step back a little bit, this consortium was founded to support social mobilization across all fourteen districts of the country. It was headed and led by GOAL Ireland, which is an NGO that had been working in Sierra Leone for many years. The idea kind of came up from Vance Brown who was there from CDC, with Katherine Owen from GOAL, and several other people in Restless Development, BBC [British Broadcasting Corporation] Media Action. FOCUS 1000 was actually the last NGO to join the SMAC consortium, but we joined them still at a very early stage where the consortium was still identifying what needed to be done. So then we used the KAP evidence to help shape that.

Essentially, the SMAC consortium--FOCUS 1000 was working with religious leaders. GOAL and Restless Development, they were working with community mobilizers. These were individuals, young people from communities who Restless Development for example had been working with in rural communities as volunteer peer 01:48:00educators. They were known to the communities. A lot of them were from the communities, so therefore, it was easier for them to go back to these communities and engage folks around Ebola prevention, Ebola treatment, Ebola containment. The idea was that we need to go in and develop action plans with communities. To go in there and say, this is what Ebola is. Have that conversation with communities, get their feedback, their perspectives and say, if we want to prevent--not having Ebola in this community, what should we do? That's what the mobilizers did. They engaged their own communities to come up with concrete plans, so they would have an action plan that may have three to five action points to say, whenever we have a visitor that comes to visit this village, they must report to the paramount chief and say who they are, where they're coming from and give their names and details. We need to be able to check on our neighbors and see if someone is sick; if they are sick, we need to 01:49:00notify the hospital.

It was coming from the communities. They were coming up with their own plans. It wasn't people coming in there telling them you need to do this, you need to do that. We know that doesn't work. You can't tell people what to do in situations like that. You can, but they are probably not going to do it. It's a lot better if you engage them in dialogue and reflection and they are able to identify what they believe they need to do to keep themselves safe. No one wants to die. No one wants to have Ebola. No one wants to see their family members suffering. So they also have an incentive and they are motivated to want to do something, you just have to guide and facilitate the process.

That was our framework. We partnered with BBC Media Action. We were able to get influential religious leaders on the radio to talk about the need to avoid traditional burials, traditional funerals. We were able to get community champions that GOAL and Restless Development were working with on radio to talk about their community action plans. Eventually, as time went on, we saw the need 01:50:00to engage the traditional healers.

Q: I'm sorry, I'm going to interject. I'm guessing that I'm going to have to ask you for a second session because if you're willing and able to do it, it would be fascinating, so that we don't rush through anything because this is really excellent. Everything that you're telling me is really good detail and I'm really valuing it. It sounds like maybe we can pick up at some point with the traditional leaders and I think it's called the Bush-To-Bush Campaign?

JALLOH: Yes, the Bush-To-Bush Campaign.

Q: I have a couple questions about some things that you have mentioned so far. Do you remember any specific passages from the Bible or the Quran that people did utilize to talk about modifying burial practices?

JALLOH: There was one that was very powerful and cross-cutting from the Quran. 01:51:00Sheik Ramadan Jalloh, he actually has a PhD in Islamic Studies. Again, one good thing about the group that we were able to pull together--these were not, how can I put it, they were not your quote-unquote "traditional" religious leaders. These were people that actually were well, well, very much educated, and they knew what they were talking about. One of the passages he identified from the Quran--and I am going to paraphrase--that says that, if you use your own hand or any parts of your own body to inflict harm on yourself, that was one of the greatest sins you can commit. In this instance, using your own hand to wash a dead body, even though you think it's something good you're doing, but once that information has been given to you to say hey, using your own hands to wash a 01:52:00dead body can lead to your own death and the death of others, that is actually a sin in Islam. Therefore, with that information that you have now, you should avoid touching the dead body even if it's a loved one because if by you doing so you're going to put yourself at risk and your life at risk and the risk of others, you're committing a--that is a sin in Islam and you don't want to sin.

It was very powerful and people started to see that, but it went beyond that. They gave examples. For example, when the prophet went into some battles and then some people died and they didn't wash the dead bodies. From the Bible, times of plagues or other epidemics, thousands and thousands of years ago where they saw people dying and then they came to figure out that you need to avoid 01:53:00physical contact with these people. They used those passages, very, very concrete examples that they drew from, and then they told stories. So it wasn't just to say don't do this, don't do that. They tell stories. They made it compelling. They made it easy to understand. They tied it to so many different things, and they did it in an interfaith manner. It wasn't just Islamic messages. It was Islamic messages and Christian messages combined. I think that was very powerful.

[interruption]

Q: We are back now and when we had left off, Mohamed had been starting to talk about traditional healers, but we thought for a second, he thought it would be good to go back and review the origins and the setup of the Islamic and Christian Action Groups.

JALLOH: Thanks Sam. As we left off, we talked about the setting up of the Islamic Action Group and the Christian Action Group very briefly and the role 01:54:00that they played, so I wanted to just get into a little bit more detail as to how that was done to get that documented. After we had conducted the KAP surveys, as I mentioned to you, we saw the need to engage religious leaders. The epi data suggested we needed to engage religious leaders because we had to shift traditional burial practices that involved the ritual of touching and washing and other types of physical contact with a dead body. The first step in terms of what was done was to identify fifty influential religious leaders in Sierra Leone--Muslims and Christians. We tapped into the Inter-Religious Council, and fortunately for FOCUS 1000, we already had board members that were part of the Inter-Religious Council, including the president of the Inter-Religious Council, the vice president, and other senior members of the Inter-Religious Council were 01:55:00board members of FOCUS 1000. So we knew these people and it was easier to be able to get them on board. They always wanted to get on board, they just didn't know how and they didn't have the support mechanism to make that happen.

Q: Can you tell me briefly what the Inter-Religious Council is?

JALLOH: The Inter-Religious Council was founded around the period of the war and then really cemented after the end of the war. The Inter-Religious Council played a very important role in the peace and reconciliation efforts in Sierra Leone following the war. It constitutes religious leaders from both the Islamic faith and the Christian faith who kind of work together toward a common cause and unite in the country. One good feature about Sierra Leone that I know we talked about before but I wanted to bring up again is that Sierra Leone is very, 01:56:00very tolerant as it relates to religion. Muslims and Christians get along very well. I wish other parts of the world were kind of like Sierra Leone in that regard. You would see Muslims that would go to a church. You will see Christians that would go to a mosque. On certain Fridays, you have families where some are Muslim, some are Christian. I think that's very, very powerful for many, many reasons. That helped a lot with Ebola and we can discuss that in a second. But this religious tolerance in Sierra Leone is a unique feature, especially when compared to some other African countries, some of our neighbors. It's quite dramatic in terms of those dynamics.

I'll give you an example. When I was in Sierra Leone, I went to all Christian schools. I probably knew the Bible more than some of my Christian friends, so 01:57:00when I came to North Carolina and I was working with the Black church, a lot of people kept asking me, how was that experience? How did you survive? You're African, you're a Muslim. How did they perceive you? I said, for one, it's all about how you introduce yourself to people. How you get entry into communities. Going back to what Dr. Eugenia Eng also emphasized in her training for her master's students that she was working with, I think it makes a lot of sense. For me, in North Carolina when I was there, I didn't have any problems going to these churches. Listening to the sermons and participating in Sunday services, in Bible study services that I would join them sometimes. It was a really great experience and I think that background from Sierra Leone where I went to Christian schools helped quite a lot. Seeing the great level of religious 01:58:00tolerance in Sierra Leone, I think that also was a good asset that helped me when I was in North Carolina doing my graduate studies. When I went back to Sierra Leone it also reinforced itself.

I will give you another example. My dad, when he took his GCE [General Certificate of Education] exam, so that's the equivalent of the SATs, his best scores were in Bible studies. [laughs] He did better than a lot of his Christian friends. Just to give examples of religious tolerance in Sierra Leone. That made it very--not necessarily easy, but easier for us to be able to pull together this national task force of twenty-five influential Muslim leaders, twenty-five influential Christian leaders to come together as one to say hey, we have a serious problem here with Ebola. Our people are dying and they are dying in huge numbers. A lot of us, even they themselves were at risk. Everyone was at risk. 01:59:00Everyone recognized that and having that religious tolerance enabled FOCUS 1000 to bring them together. We had a good enabling environment to work in.

With that said, we called an initial meeting with these fifty religious leaders. It was a very tense moment, a lot of confusion in the country at the time, a lot of uncertainty in terms of what was going to happen. It was right after that CDC study and projections, the modeling data that came out showing that there were going to be hundreds of thousands of potential Ebola cases if the then-present trend had continued. Fortunately, that was not the case because of the enormous interventions that took place between those predictions and the months to follow.

Q: So this would have been late September, early October?

JALLOH: This was later September. That was when we started talking about putting together this intervention with religious leaders through the Social 02:00:00Mobilization Action Consortium, for short, SMAC. Around that time after we called that first meeting, we presented to them the state of affairs. We explained what was happening from more of a scientific perspective, but also in a very applied manner, so that they can understand what was happening. We explained to them in very layman's terms so they can understand risks, factors. We highlighted this area of transmission through traditional practices revolving around burials and funerals, whereby the corpse would be touched, prayed upon and kissed and all these other kinds of stuff. Once they got that information in a very concise manner, and we engaged them in dialogue--it was very important to engage them in dialogue. In FOCUS 1000, we have an approach that we call the DRAFT approach. That's what we used to engage the religious leaders and also the 02:01:00traditional healers. I'll give you a brief overview of what the DRAFT approach is.

DRAFT, it's an acronym for Dialogue, Reflection, Action Planning, Facilitation and Tracking Change or Tracking Results. So that's DRAFT. DRAFT is pregnant. The A in DRAFT is what's pregnant. It's pregnant with something we call SKIN. SKIN, when you're doing your action planning, is to identify the things that you can stop, things that you can keep and improve, and the things that you need to do that would be new. S-K-I-N. Stop, Keep and Improve, New.

The first phase as I mentioned to you was calling these meetings, engaging these influential leaders in a dialogue. We didn't talk down to them. We didn't come in there and preach. We gave them the signs and what was happening in very easy to understand language. We heard from them what their concerns were. It was a 02:02:00long discussion back and forth, dialogue, and then following the dialogue we sat together and we reflected. It was joint reflection to say okay, this is what's happening in our country. We are all concerned. We don't want this to continue. What should we do now? If we don't want to see more cases, what should we do? We just asked them these questions. They themselves would start talking to say hey, based on what you're saying, we're seeing a lot of cases linked to traditional burials and we know of our fellow imams, fellow pastors who've participated in these kinds of burials in the past month, in the past week, they've been infected. They've died, their families have been infected, they've lost family members. We understand. It makes sense. It wasn't like something theoretical. They got it and they said yes, you're right. This is one area where we believe as religious leaders, we are a trusted source on this message and we would be 02:03:00willing to do something about this.

Now we're reflecting to say okay, what can we do? That's when you shift into action planning to say, we don't want to see imams and pastors dying. We don't want to see families of imams and pastors dying. We don't want to see anyone really dying unnecessarily when we can prevent a lot of these deaths. As a result of that, they came up with their own actions. We didn't impose these actions on them. They said, one, we need to go back to our books because for all of our lives we've been told and we've been telling people that this is how they should handle the burial of someone, a family member, appropriately, based on our own religious and cultural traditions. Now if we're going to change that narrative, we have to be able to have evidence to support that so we don't look foolish. [laughs] They went back, they did that research and we've talked about that already and came out with concrete supported messages for Act Against 02:04:00Ebola, which were the more scientific-driven messages on how to prevent Ebola.

Following that, we then said okay fine, we have this national task force. They appointed who was going to be on the national task force. We didn't do that. Following that, they then also said, we have to be able to have a local presence. We have to be in the district. Let's identify a district coordinator for the Islamic Action Group in each of the fourteen districts of Sierra Leone. Let's identify a district coordinator for the Christian Action Group, so then they did that. They identified those individuals. We did a similar DRAFT and SKIN session with the district coordinators, got them on board. Following that, we developed all of these materials as I was telling you about, the manual that highlights these messages and then the prototypes. Sermons, all of that was put together, and they went out and then rolled out these trainings on their own. We 02:05:00were there to support them, give them the logistical support. We had gotten funding from DFID to support this work through SMAC, so we were there as facilitators, not the doers. They were the doers. They were the ones leading a lot of these interventions on their own with our support and technical assistance where and when necessary.

They went out, they trained six thousand religious leaders all over the country in every single district of Sierra Leone. In addition to the district coordinators, they also identified and trained chiefdom-level coordinators because the way Sierra Leone works, you have the district, within each district you have chiefdoms, that's the next level. It's kind of like the counties within states. Within each of these chiefdoms you also have sections. They also appointed two individuals in each of the sections to serve as coordinators. So you can see the cascaded coordination structure from district to chiefdom to 02:06:00section, and from the section level, then you're now at the community level or the village level. That was kind of like the infrastructure that they pulled together with our support.

I want to give you one anecdotal--well, just one small story of Kambia. It goes back to this issue of religious tolerance. Even though you have village tolerance, there are times when you can have some tensions, as you can imagine. In Kambia, the two district coordinators that were appointed, they knew each other before, but they never interacted. They knew each other, but never were friends, they were never really in the same space. They respected each other of course and no one bashed the other one or anything like that, but they had some tensions. There were times when on Fridays, maybe the church is having some kind of a loud prayer session or whatever it was, maybe some music playing and then the mosque, they're trying to have Friday prayers. Some Friday prayers when the 02:07:00Adhan is going off in the morning the church didn't quite like that, so there was some of that tension going on. Now they are appointed to work together and they understood what it meant. So Ebola brought these two gentleman together, the imam and the pastor in Kambia. The community was so shocked when they saw these two, the imam and the pastor. I don't want to say they didn't get along, but they weren't really close before. Now, they're sharing the same motorbike together. People started making jokes, now the imam is now a pastor, the pastor is now an imam. It was kind of confusing. Nonetheless, they got along and they worked very, very well together. They supported the District Ebola Response Center, which is the DERC, which falls under the National Ebola Response Center, the NERC. These were the structures--the formal government structures responsible for the response. At the national level you have the NERC, at the district level you have the DERC, which is a mirror of the NERC at the district 02:08:00level. So they worked very closely with the NERC. They attended all the NERC meetings together. They were there, and this was happening in all other fourteen districts in terms of the religious leaders being involved in the formal response. I just wanted to kind of highlight that.

Following all of that engagement and the training of the religious leaders between October and December, by January, we started to see a huge drop in the number of cases because there is now this wide-scale social mobilization community engagement intervention in Sierra Leone with religious leaders, with the community mobilizers that I mentioned already, who were mainly young people who were formerly volunteer peer educators in their communities. After we rolled out these training and this ongoing engagement with them, in January 2015 we started to see a sharp, sharp decline in the number of new cases of Ebola in Sierra Leone, and that continued. It was around that same period where--we were 02:09:00still having cases. Two cases here, three cases, five cases, six cases, and then we had a huge cluster in Bombali [District]. The religious leaders got together with the mobilizers and the local radio stations to put together something that's more integrated, so it's not disjointed. So then you can have religious leaders on the radio promoting these messages. You can have religious leaders and the community mobilizers making joint visits to homes that were quarantined to provide psychosocial counseling, etcetera, etcetera.

As that was going on, we knew that it will be very important for us to be able to get reports back almost on a daily basis. We had six thousand religious leaders, GOAL and Restless had two thousand--close to like seven thousand people that we needed to get information from in terms of the activities that they were 02:10:00doing. And also to get a better understanding of the number of suspected cases that they were identifying in their communities, and what actions they were taking. And then also the deaths that were occurring, and whether or not these deaths were being reported to the burial teams, and if these deaths were being afforded what was being called "safe, dignified medical burial," which was the safe alternative to the former traditional burials. To get that information in real time was nearly impossible because that information was being collected by paper and then we said, you know what? The opportunity came with [the Bill and Melinda] Gates Foundation to say, how can we support the SMAC consortium? We know you guys are doing good work. We said well, one area of need is to digitize how we're getting this information, so we can be able to get the information in real time, get it fast and we can take action on this information without waiting months and months for the papers to come back. We have to analyze that. It takes a long time. Gates gave a grant to SMAC consortium. A huge part of that 02:11:00grant went into digitizing our data collection efforts from the religious leaders in the community mobilization, etcetera, etcetera.

Starting around March, as you can imagine, it took some time to develop these systems and train people. You had religious leaders, you had community mobilizers in communities. They had their very basic Android smartphones. As they were going out to houses, engaging communities or whatever, they were also reporting back on what they were doing. They were reporting back to us on sick cases that they identified, deaths identified and all that information was coming back. Thousands and thousands of records that we were collecting on a daily basis in a very structured manner. This was perhaps the first time in any outbreak setting where you [were] able to get that kind of real time data on 02:12:00social mobilization. Normally, you get that kind of data on surveillance or case management, that kind of stuff. In terms of community engagement, this was something that was very new. We had indicators that we were monitoring over time, and as that information was coming in we were passing it onto our district liaison officers, who were already embedded in the DERCs.

For example, if there is a death that took place, but the burial team had not responded, let's say a religious leader or a community mobilizer would send us an alert. When they send that alert, we will see it and then when we see that, that same information gets passed on to the district liaison officer. So he would know that there's a corpse somewhere in the district, where they need to pick that up, and then he will channel that information to the burial team. The DLOs, the district liaison officers, were embedded with the DERCs, so therefore they knew who the burial team representatives were. They would meet with them and share that information that they were getting from the digital system that 02:13:00we had put together as part of the SMAC consortium. I don't know if you have any questions around that.

Q: Was there a specific program that you were using on the smartphones? Or what was that?

JALLOH: We had two types of programs we were using. The first is to collect daily, in real time information using RapidPro. There's a version of RapidPro that is more open to the general public called TextIt. They're all the same. The RapidPro technology was used. It's SMS [short message service] based, so basically you would send--we had registered everyone's phone. We knew who the phone belonged to, what district they were in, etcetera, etcetera. Then they would send an alert to a short code, 334. If they send--let's say they send the phrase "death" for example to 334, we knew that there was a death and we knew 02:14:00where that death was. They will get another SMS text, it was interactive. The follow-up SMS text will then ask them, what has been done about this death? Reply back with "1" for this. So it was like back and forth being able to interact and get prompts from the system automatically and that information is stored and shared with the DLOs, and then we also stored on a more long-term basis and we were able to analyze that and see trends over time. For the weekly reporting in terms of their activities that they were undertaking, we used ODK, Open Data Kit, to collect that information and they would submit that also to us using their smartphones.

Q: One question about just timeline. The NERC and DERC system, that wasn't 02:15:00immediately part of the response. Did that develop with the militarization of the response?

JALLOH: The first part of the response from the beginning when we had the first case back in May up till September, the Ministry of Health and Sanitation, MOHS led the Ebola response and the coordination of it. There was a need that emerged to improve the coordination, to go beyond the Ministry of Health because Ebola was a national emergency, not just a health emergency. It was a social problem. It was an economic problem. It had a lot of other ties, so the government decided that you needed a new coordination entity that was going to be in place to oversee all of these things, going beyond health--meaning the traditional sense of health, to cover psychosocial aspects of the response. To cover 02:16:00incorporating the armed military and the non-armed military component of the response. That became a big part of the response because they were responsible for pretty much getting everyone on the same page, which as you can imagine, you have many, many, many national partners, many, many, many international partners. It was very challenging to get everyone on the same page, but that was their task and I think it was a learning process for the NERC. They came in, first they had to move away from the MOHS [Ministry of Health and Sanitation] system that was in place into developing their own standard operating procedures for how to do business, and then the EOC was built and then the NERC was responsible for the Sierra Leone EOC, the emergency operations center. They had daily briefings to look at the state of the outbreak in Sierra Leone, the 02:17:00epidemic curve, and understand where new cases were coming from, what interventions were taking place, where the needs were, who was being infected, how, when, where, that kind of stuff. To plan around that nationally, but also coordinating with the DERCs at the district level. That was really what the role of the NERC was and that was their relationship with the DERC as well.

Q: I know at one point you mentioned maybe imams, pastors getting on the radio and sharing messages. Can you talk about methods of communication and how you knew which methods were the best?

JALLOH: The imams and pastors, they use various methods of communication. First and foremost, they already had a mosque or a church. They had their regular prayer services. In addition to that, they have Friday services, the Khutbahs, and then you have the Sunday services that would attract hundreds of people 02:18:00usually for most of the mosques, some more than hundreds. Therefore, that was a captive audience that they had, at the very minimum every Friday, every Sunday. They are standing there in a position of influence, able to pass on information. That was one avenue they had. Another really, really neat avenue that they had to share information and engage in dialogue was using radio. Our partner, BBC Media Action through SMAC, they had a network of forty-two-plus local radio stations. Some were national, but a lot of these were small, local radio stations. They were producing programs in local languages and you had these imams who were from those local communities getting onto the radio, engaging in these interactive radio discussions. At the end of the discussion, the radio panel for example, they will have people that would call in or send text messages and then they would engage them in that way.

For example, CDC had a radio program with Africell Radio called the Big Idea of the Week that was built off of the comprehensive messaging guide. We had the messaging guide, but we didn't want it to just be a document that was just sitting somewhere. We said, how do we turn this into an interactive tool? So CDC was there providing technical assistance and helping to guide those conversations on radio and looking to make them more interactive and to get communities involved and engaged and participate in the process. The Big Idea of the Week for example, they will take one subject, let's say safe burials, and that will be the big idea of the week. Let's focus on burials. Or maybe another week they will take stigma and discrimination against Ebola survivors. Another week, importance of seeking care. Another week might be things you can do while you are waiting for help to arrive, like providing ORS [oral rehydration solution] to a sick family member. It was easy to get the message focused that 02:20:00way, so you are just taking one idea, you focus on that for the week. Before that, you had ten, fifteen, twenty, thirty different ideas all over the place, not coordinated. But the Big Idea of the Week, the whole premise was that if you can have these radio conversations, but beyond that even at the community level in the mosques and churches, everyone was talking about one thing at a time and then that one thing should be linked to what the epi [epidemiology] was saying for that week or for that month.

Q: Were you involved in the Big Idea of the Week?

JALLOH: Yes. CDC was part of the SMAC consortium as well as technical advisors, not as implementers. We all worked very closely, so they were many, many--there probably were over fifty radio programs in a matter of just a few months. Probably over one hundred radio programs that I participated in on a daily basis. Some of these were national radio programs that were simulcast over forty stations. Myself, other people from FOCUS 1000, other people from the SMAC 02:21:00consortium. Sometimes when you had CDC staff such as Desmond [E.] Williams and other CDC staff that were Sierra Leoneans, they would also get on the radio and help pass on some of these messages.

Q: One note that I have here, and I want to make sure that we have it and we might, is to talk about community action plans. Have we really gone over that do you think?

JALLOH: We've gone over it. I can touch on it just a little bit more.

Q: If there is something there you think we should capture that we don't have already.

JALLOH: Sure. The community action plans, our SMAC partners, GOAL and Restless Development. GOAL focused on Western Area, which has about thirty percent of the population in Sierra Leone. Restless Development covered the rest of the country, mostly in the rural parts of Sierra Leone. A big task that they had was to work with these community mobilizers to put in place community action plans. 02:22:00There were two phases to the community action plans. The first phase was the triggering phase. The community mobilizers would go into the community and trigger these plans. The first thing they would do would be similar to what we did with the religious leaders also--to identify the influencers, the champions in these communities. That could be a religious leader, it could be a chief, it could be some other community leader. It could be a women leader, it can be a youth leader. It's not just one person, so usually like five, six, seven, eight, ten influential people from that community that they would identify, bring together and then they go through this participatory process of engaging them in dialogue, reflection, and being able to identify concrete areas where the communities themselves will say, these are the things that we want to do in our community. They might say, we want to set up a checkpoint. Some people might say, we need to make sure everyone who enters this community is going to wash their hands. Whenever there is a death, we want to make sure that that death is 02:23:00reported, and if there is a family that is in quarantine, we want to go there and check, without going into the house. They can stand outside and then from a safe distance and check on those people. If there are people who are getting sick in the quarantined homes, they can help report that. It was all left to the community, so it could have been almost anything, but many times these were meaningful action plans that the communities themselves were able to set and put in place.

So that's phase one, where they do the triggering. Then they'll do follow-ups, that's phase two. The triggering was like a one-off activity, but the follow-ups, those were continuous. Every week they'll go to these communities, they'll meet with the community influencers and the champions to go back and review the action plans, understand how they were being implemented. And they would use their phones to report on these action plans, so we have concrete data on the percentage of communities that are on track with their action plans. Communities that are failing to implement their action plans, etcetera, etcetera.

Q: We should get to reaching out to the traditional healers.

JALLOH: Yes. Part of 2015, the beginning part of 2015, as I mentioned to you already, the number of cases dramatically decreased. Good news for everyone in the response. However, with Ebola, until you get to zero and you stay at zero for forty-two consecutive days without any confirmed new case, you are not safe. That was it. So even though we were seeing fewer and fewer cases, we started to see more cases linked to traditional healers. Mainly in Port Loko District, Kambia District and Western Area, which is the capital. That was picked up by the surveillance teams and the epi teams who said hey, a lot of these new cases are linked to traditional healers and traditional healing. The NERC then reached 02:25:00out to FOCUS 1000 and said, we know what you guys have done with religious leaders. We've seen the fruits of those engagements and we believe that they've been successful. We like the approach you've used and we think that you're in a good place to also come up with an intervention with the traditional healers.

To make it short, we went through a similar process. Our process is pretty standard. We identified the leaders within the traditional healers. Fortunately, they had a union already. Sierra Leone Indigenous Traditional Healers Union, SLITHU for short. We reached out to the SLITHU leadership, starting with their president. They have a very, very dynamic, very powerful, very, very influential president, Alhaji [Sulaiman] Kabbah. So we reached out to him and his leadership team, similar to what we did with the religious leaders. We explained to them 02:26:00without blaming them to say look--and we went there with a lot of evidence to say look, the past month for example we've had ten cases, just as an example in Sierra Leone, five of these cases were linked to traditional healers. We gave them details: where it happened, how it happened and what was involved. We were very open with them and they took the information. They were not defensive because we didn't go there blaming them. They said okay, we can do something about this. Then we engaged them in reflection and action planning and said well, what do you guys want to do?

At that time, Sierra Leone had conducted two House-to-House Campaigns. These were three-day campaigns where everyone would stay at home. The local word for it is Os-to-Os Campaign. A lot of people had thought, maybe the traditional healers should be part of the contact tracing teams. So we brought that idea to them. They rejected it. They said we are not contact tracers, we're not 02:27:00surveillance officers, we are traditional healers and as traditional healers what we want to do is to mount a Bush-to-Bush Campaign. We had never heard of such a thing before, so we said, what does that look like? They said, it's kind of similar to what--and they said "you all," meaning medical people and public health people. It's kind of similar to House-to-House, but this time we'll be going from one secret shrine to another secret shrine to see what is happening there because that is the only way we can enforce whatever regulations we come up with.

Then, they set the tone right and they effectively banned all traditional healing in Sierra Leone to say, until Sierra Leone is out and there are no more cases of Ebola in Sierra Leone, you cannot have any traditional healing taking place. Again, it's easy to say that even if it's coming from their leadership. To make that happen they needed the Bush-to-Bush Campaign. Before we got to the 02:28:00Bush-to-Bush Campaign, it's a long process and engaging communities is a process. That's one thing also I wanted to mention. It's not something you can just wave a magic wand and then the communities are engaged. It doesn't happen that way. It's a process. It's a step-by-step process. It's iterative. Sometimes you make progress. Sometimes you come back and then things you might agree on you come back and disagree. You have to be willing to be flexible.

With that said, we met with them and then they said, let's call a national meeting in Freetown. They invited other respected traditional healers from various parts of the country. They came to Freetown and we held a day-long, consultative meeting with the traditional healers. This was facilitated by their president and by their leadership. He did the same thing we did. He gave them the signs, told them what was happening. Told them his policy on banning all 02:29:00traditional healing in Sierra Leone and informed them there is going to be a Bush-to-Bush Campaign and that this is something that should be taken very seriously because we cannot get to zero as long as we're having transmission chains linked to traditional healers. He emphasized that he did not want to see traditional healers as the stumbling block to getting to zero in Sierra Leone. They took the message to heart and they all agreed and committed to his vision and what he was laying out with the Bush-to-Bush Campaign.

We helped facilitate and organize and coordinated in partnership with the traditional healers the Bush-to-Bush Campaign. That involved many, many meetings. I was in Port Loko District, Kambia District with the leadership of the traditional healers there working with them to operationalize the Bush-to-Bush Campaign. To get it linked with the district Ebola response, so that it's not just some ad hoc activity by itself, getting support for it. There 02:30:00were lots and lots of schools of thought in terms of how traditional healers should be engaged. Our approach was not the popular approach at first. There were many that--when I got to Port Loko District, for example, they already had a plan to engage traditional healers, but that plan did not include engaging the national leadership, the formal structures through the Sierra Leone Indigenous Traditional Healers Union, SLITHU. That was the first non-starter. You cannot engage traditional healers and not do it through their union. The reason they were saying at that time in Port Loko was that you have thirty thousand traditional healers in Sierra Leone, they said they were all independents, they were not organized, and therefore, it's easier to just engage each district separately. It's like taking a more decentralized approach. That's what they wanted to do. There was nothing wrong with that because eventually what we did 02:31:00was a combination of a centralized and a decentralized approach, but we had to go through the proper channels to get that done.

Another thing they were talking about and exploring in Port Loko at the time was to provide incentives, financial incentives to traditional healers to get them to not engage in traditional healing. The theory was that traditional healers, they get their livelihoods from practicing traditional healing and this is a fact. We were sensitive towards that. With traditional healing banned and people losing faith in traditional healers, their business model was adversely affected. As a result of that, a lot of people in the response at the time--I mean key, key partners who had this mindset that let's hire traditional healers as part of the response. Let's get them embedded with contact tracing teams and let's incentivize them to report people that are coming to them, so that 02:32:00whenever someone comes and they are sick, they will say no. I'm not going to treat you. Then, they'll refer that person to the hospital, then that traditional healer would get a small token of appreciation, like I don't know, two dollars, three dollars, the conversion at the local rate was something like ten, twenty thousand [leones]. The details were not clear. We looked at that, meaning FOCUS 1000. We saw a lot of problems with it, so we did a formal analysis of the various incentive packages that were being proposed. We came to the conclusion that it is going to cause more problems than it's going to solve and we said we don't support this idea and we gave rational explanations for that.

One of them is that you have thirty thousand traditional healers. Anyone can claim to be a traditional healer. How do you identify who's a traditional healer, who's not a traditional healer, who gets to say who's a traditional 02:33:00healer? It gets complicated. Let's say you get beyond that, you're able to identify all the thirty thousand traditional leaders in Sierra Leone, the next phase would be administratively, how do you handle that? People will start reporting cases. What if you're not able to give them that incentive, they become dis-incentivized, and that was going to cause a lot of problems. Then you had people like the religious leaders who were mostly volunteers working months and months prior to that, and you didn't pay them. Now you're going to start paying traditional healers? So we pushed back against that for many, many reasons. What about if some of these traditional healers start telling people when you get sick, come to me first so I can get ten thousand leones, which is like two dollars before you go to the hospital? You can see already, lots of complexities surrounding that, so we pushed hard against that idea. Eventually, the National Ebola Response Center, the NERC, came out with very clear directives. Their CEO, Major General [Alfred] Paolo Conteh came out and said 02:34:00that he's not going to support any incentive package to traditional healers and that all partners should work with the proposal that we had put forth in partnership with the traditional healers union. So that was the first battle. I spent a month trying to get that done myself, and others who were involved. I was in Port Loko and Kambia.

Finally, we got over that. Once we got over that, then we had to do mapping of traditional healers in Port Loko and in Kambia. Then we worked through their network. They didn't have the kind of infrastructure and the capacity to do that, so we helped them develop a very basic Excel database. Who the traditional healers were, names, locations, phone numbers, their role, their gender, age, blah, blah, blah. In a matter of just a week, we pulled together a database of 02:35:00over three thousand five hundred traditional healers in Port Loko and Kambia, which were the two key districts where we kept seeing cases linked to traditional healers. Once we knew who we were engaging, then we brought the DRAFT approach. In each of these districts we have the head of the traditional healers unions. He would go there and kick off the Bush-to-Bush Campaign. He kicked it off not just at the district level, he went to every single chiefdom and then they will choose one section within the chiefdom where they will actually do a full Bush-to-Bush Campaign to roll out how the Bush-to-Bush Campaign should take place. Part of what we did we said okay, it's very customary in the culture of Sierra Leone, when you engage people--sometimes you're going to someone's house--you bring a little gift. So we said instead of giving them cash incentives, why don't we do just a one-off food package, like 02:36:00some rice, oil, some basic things to recognize that they're making a huge sacrifice, they're not going to be getting paid for this, and they are volunteers. That's what we did. It worked very well. The traditional healers union, they were responsible for rolling that out; we were there to support and ensure compliance and all that kind of stuff and make sure there was no fraud involved in the process and that it was very transparent.

We worked with them to roll that out in every single chiefdom and section in Port Loko and Kambia. It was a huge undertaking. It lasted for a month, and you're talking twenty vehicles of the traditional healers union and many, many motor-bikes just going around. Just to give a more detailed description of what it entailed once they got at the local level: they would pull together the senior traditional healers in that community. They assigned them roles officially, and their task was to go to every single secret shrine. First of 02:37:00all, only the traditional healers knew where the secret shrines were. The secret shrines were usually in the bush somewhere, which is why they called it a Bush-to-Bush Campaign. Not only are they the only ones who knew where these places were, they are the only ones that could go there. I will never go to a secret shrine of where traditional healers are doing their secret traditional healing practices. It's not acceptable and it's probably not safe. Therefore, we got these traditional healers themselves to lead the Bush-to-Bush Campaign, and that's what they did. They went to secret shrines. They would check to see if the shrines were operational and check to see if there was anyone there, and they kept doing that continuously. They had small teams that they had formed all over the district and they kept repeating that over and over and over and over to make it clear that you cannot go see a traditional healer. A traditional healer is not permitted to treat any patient during the Ebola outbreak. It was 02:38:00highly successful.

In Kambia, some of the traditional healers fled. They went to Guinea. They went to Forecariah, which was right across. That caused some problems too because if they move and they continue those practices in Guinea, it was going to be a problem. That called for cooperation with our partners in Guinea. The Sierra Leone Kambia DERC had a partnership with the response in Forecariah, Guinea, and they tried to address a lot of those issues there as well.

Q: Just to get a quick sense of the timeline. In what months is this taking place?

JALLOH: The initial engagement started in April, and then by May we had some of the national engagements where we brought them together. By June we were out in the districts. The Bush-to-Bush Campaign officially kicked off end of July and went through all of August, 2015. That was the last leg of the Ebola response. 02:39:00Literally, the last few cases that we were seeing, they were essentially all linked to traditional healers. So, this is Epidemiology 101. You go to the source of the transmission. Once we were able to get to the bottom of that, once we eliminated those transmission chains, by end of August 2015 we essentially eliminated all transmission chains linked to traditional healers in Port Loko, Kambia, Western Area. Almost immediately as these transmission chains were being eliminated and new ones were not surfacing, we saw the end of cases in those districts. Then by September, we started recording multiple days, consecutive days of cases not reported, and the new cases that were being reported, these were cases that might have been missed out, unknown transmission chains, but we didn't see any more transmission chains linked to traditional healers after that point.

In November 2015, early November, I think it was November 7th, that was when 02:40:00Sierra Leone was declared--officially declared Ebola free after going through forty-two consecutive days. Starting like end of September, we weren't seeing any more cases of Ebola in Sierra Leone. That went on for forty-two days. We got to early November and Sierra Leone was declared Ebola free for the very first time.

Q: How did that feel?

JALLOH: I was in Guinea. [laughs] I wasn't even in country. I was actually in Guinea supporting some response activities in Guinea, helping to finalize a KAP survey, helping to do some similar work in Guinea. It was a moment of relief for all of us. It was like wow, we always envisioned Sierra Leone becoming Ebola free. Ebola had been part of who we were after a while and it was hard to envision what life was going to be like after Ebola. Ebola was like our lives, 02:41:00and then Ebola ended, at least for that moment. Because with Ebola, it never truly ends. Once you have Ebola in the country, you're always going to have flare ups. That happens. We saw that in Sierra Leone. But you know what? We enjoyed that moment. We celebrated. I was in Guinea. I couldn't be there in person to celebrate. It was a huge, huge celebration, and it marked a very historic moment for Sierra Leone and really for the sub-region in West Africa really.

[break]

Q: Maybe the most important thing to do right now would just be to talk about what you have done since. So you were in Guinea, you were implementing KAP studies there. Bring me to now, essentially.

JALLOH: We ended that first outbreak of Ebola, and then we saw another flare-up that happened in Sierra Leone in early 2015. In January 2015, exactly January 02:42:0013th, 2015, right after WHO had declared the entire region Ebola free. Hours later, we had a confirmed new case of Ebola in Tonkolili District in Sierra Leone. That case originated from Port Loko District. The patient had gone to Kambia, to Bamoi Luma market, and came back to Port Loko and then left Port Loko. She was there for a few days. Slept in the same bed with other people, so potentially exposing them, and then she left and went to Tonkolili and then went to the hospital. Unfortunately, she didn't present all the symptoms required to be triaged as an Ebola patient, therefore she was sent home. Because she continued to be sick, her family took her to a traditional healer, and then they had another traditional healer that came from Bombali to visit her at home. It 02:43:00was a very, very complicated new case. One more case came out of that case, so again, everyone was scrambling around to say hey, we need to do something now. Learning from the past experience with Ebola, the first forty-eight hours are critical. What you do in those first forty-eight hours, first being able to detect that you have a new case, which is something that probably could have been detected a little earlier if a blood sample was taken from that patient in a hospital and tested. That did not happen, but when they swabbed her corpse, they were able to detect that she was indeed an Ebola confirmed case. That was the first good news that happened, was that the case was actually detected. You have to detect the case.

After the case was detected, it was a bit slow in terms of getting the contact tracing up and running because that's the next phase. Once you detect the case, 02:44:00immediately to kick in and have swift contact tracing. That was key in Nigeria. We saw what happened in Nigeria. Nigeria could have had an exploded Ebola outbreak, but because they were able to quickly detect, quickly respond, that was key. Then they were able to prevent. These are key elements, being able to prevent. If you fail to prevent, then you need to be able to detect, and then after you detect you have to be able to respond. So it's prevent, detect and respond. In Sierra Leone, I think we learned in terms of doing a lot of these different things to prevent, but this case was quite bizarre. At that point, people didn't really know where the case had come from, but we failed to prevent it, but we were able to detect and I think overall we were able to respond.

Part of the response involved getting religious leaders involved again. Getting traditional healers involved, and this time we also worked very hard to embed 02:45:00the traditional healers, the religious leaders as part of the contact tracing teams because we were facing pushback from communities. It was really hard to gain entry into communities. Communities were really sick and tired of Ebola by this point. They didn't want to hear it anymore. They thought it was like a government ploy to get funds back into the country by having Ebola. There were lots of misconceptions and rumors surrounding that new case, so it was important to get religious leaders and traditional healers and other community actors and community members involved in that. I think that was a key lesson we had learned from the prior response and we were able to apply in this new response. Hopefully, the country will be able to keep applying those lessons moving forward.

Q: Let's talk about moving forward. In FOCUS 1000, you were a key partner for CDC and now you're working for CDC. Tell me about that.

JALLOH: Yeah. I managed several CDC projects while I was in Sierra Leone. Not directly from CDC because it came through CDC Foundation, but CDC was a strong partner as a technical partner on a lot of those projects. On the KAP surveys, worked very closely with CDC. When CDC was doing the STRIVE [Sierra Leone Trial to Introduce a Vaccine against Ebola] Ebola prevention vaccine trial in Sierra Leone, I led the formative research for that. Several other initiatives that I worked with CDC on. In doing that work, I really respected CDC and their perspective and the approach that CDC took in terms of engaging in the Ebola response. That really inspired me to say hey, as someone who is a public health practitioner, I think the opportunity to join CDC would be really a great honor. I saw an opening for a position that I thought would be a good fit with my 02:47:00background as an epidemiologist within the Division of Global Health Protection. What was attractive about this opportunity was that it would allow me to spend a good amount of time in Sierra Leone and Liberia in these Ebola-affected countries and provide technical a ssistance and support to the CDC country offices there. To support the government of Sierra Leone and Liberia under really the Global Health Security Agenda. To be able to prevent global health security threats, and when we do have global security threats, to be able to detect these very swiftly and then be able to respond accordingly.

I think being here at CDC, at DGHP, there are lots of good opportunities that I think I'm involved in now and I really appreciate. I think having that opportunity to work with CDC in country and now here in Atlanta, I have a unique 02:48:00perspective that I think I bring to the job and being able to add value to what CDC is doing in these countries.

Q: Thank you for that. I know that we could probably talk for a while more on this. Very briefly, you mentioned organizing or running the formative study for STRIVE. Do I have that right?

JALLOH: Yeah.

Q: Can you talk about that for just a second?

JALLOH: Sure, I'll talk about that for a second. That was very important. We know the role that vaccines play in preventing diseases. There are lots and lots of diseases we can easily prevent through vaccines. Measles. Lots and lots of other--polio, we are close to eradicating polio and that's because of vaccines. There was no vaccine for Ebola. Even right now there is no approved vaccine for 02:49:00Ebola, but when Ebola hit we had to think outside of the box. There were some trial vaccines that were ready in the pipeline and CDC had a trial vaccine that was in the pipeline already. When Ebola hit, a lot of people at very senior levels thought that we have to be a bit untraditional in the sense that we have to speed up the vaccine trials and we don't have to wait for thousands and thousands of people to die for us to then come up with a vaccine later. Said this is the opportunity to actually use the existing vaccine that had already gone through some safety trials, potentially could be of benefit to people in Sierra Leone, especially those that were at high risk. That would constitute the healthcare workers and family members of those who were probably high-risk contacts. Therefore, the vaccine, there was a very, very strong case for the 02:50:00Ebola vaccine. If we had a vaccine for Ebola, we would not have seen the scourge that we saw in Sierra Leone as a result of Ebola.

Q: So tell me in practical terms what you did for STRIVE.

JALLOH: As you can imagine, in the middle of the outbreak where there were lots of misconceptions already in terms of the origin of where Ebola came from, there were people in Sierra Leone that I talked to that thought that maybe CDC had a role with the United States government, or foreign governments had a role in getting Ebola to West Africa. They were always skeptical about foreigners, skeptical about the agenda of a lot of these international organizations. You have people who had those concerns. So if you're going to try and roll out a vaccine, you can imagine there could be a lot of potential pushback and resistance from communities and that can backfire in a huge, huge way.

Therefore, CDC said we need to do formative research and really understand the 02:51:00perspectives of potential recipients of this vaccine to know what their concerns were, if any. To understand the factors that may motivate them to want to be able to participate. To understand their fears. To understand a whole host of issues, so that we can better be able to inform the vaccine trial. What I did as part of FOCUS 1000, I led a team there that did the formative research for CDC. We did a mixed-methods study, including in-depth interviews, focus group discussions, and then a survey among potential vaccine recipients. Also, we helped do some material testing. A lot of the materials that they were developing to communicate the vaccine trial to potential recipients, we helped 02:52:00test those materials to see if they were culturally appropriate. How people were perceiving these materials and how we can improve these materials overall to be able to understand ethical considerations regarding the vaccine, etcetera, etcetera.

The findings from the formative research were very helpful [coughs]--the findings were very helpful in the sense that they helped shape how the rollout took place in terms of recruiting participants, insuring ethical considerations and things like that. [coughing] I don't know what's going on.

Q: That's okay. I think we're out of time, and your health is failing! [laughs]

JALLOH: Yeah, my throat got tired.

Q: I can't thank you enough for being here Mohamed. Very much a privilege to sit 02:53:00here with you and hear about all of your months of experience and everything leading up to that. Thank you so much.

JALLOH: No, thanks. I appreciate the opportunity and I think it's important. A lot of times we're there, there's a lot of stuff happening and we don't have the time to sit down and reflect on these things and record and document them, but I think it's really good to do that. So thanks for having me.

Q: Of course. With that, thank you.

JALLOH: Thank you.

END