Dr. Oliver Morgan

Dr. Oliver W. Morgan

Q: This is Sam Robson here today with Oliver Morgan. Today's date is May 25th, 2016, and we're here in the audio recording studio here at CDC's [Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Oliver today as part of our CDC Ebola [Response] Oral History Project, and this interview follows one done by Mark Honigsbaum of the Wellcome Trust back in October of 2015, which I believe we'll be able to archive here also at the [David J.] Sencer [CDC] Museum. So that's cool. Oliver, thanks so much for being here.

MORGAN: Sure, my pleasure.

Q: And could you tell me, at the outset, your full name and your current position at CDC?

MORGAN: My name is Oliver Morgan. Currently, I am serving as an advisor to the World Health Organization on behalf of CDC.

Q: Great. Thank you. Can you tell me when and where you were born?

MORGAN: I was born on the 26th of March, 1973, in London.

Q: And where did you grow up?

MORGAN: I grew up in the UK [United Kingdom]. I did all my schooling and my 00:01:00university in the UK, and actually only came to CDC quite recently in 2007 to do the EIS [Epidemic Intelligence Service] program.

Q: Where exactly in the UK?

MORGAN: I'm from London. I'm from Central London.

Q: From Central London. What was it like growing up there?

MORGAN: It was pretty different from the way London is now. In the 1970s, 1980s, it was a difficult time for the UK. We had some difficult economic times, and there was decline in the UK manufacturing. There were some political troubles. But it was a good time to grow up in London, actually.

Q: Who was in your household, growing up?

MORGAN: I'm one of three brothers. So my two parents, and the three of us. We also lived with my grandmother, and pretty much lived with my aunt, who's my mother's sister, who was effectively in the house every day.

Q: Gotcha. What did your parents do?

MORGAN: My father is a mining engineer, and my mother is an obstetric anesthetist.

Q: Cool. What kinds of things were you into as a kid?

MORGAN: A lot of outdoor stuff. I used to go out hiking and rock-climbing in Wales a lot, doing a lot of mountaineering. I used to enjoy cricket and rugby when I was younger. I kind of gave it up when I left school. Some of the things I remember was going camping when I was young with my family, going off to the South of France, camping.

Q: Nice. Up through about high school, what did you think you were going to be, as an adult? What kinds of subjects were you interested in, in school?

MORGAN: I was a terrible student all through my formal education, all the way 00:03:00through to university, actually. I was not very focused on a formal career, at that stage. I was quite interested in music, more interested in the arts, probably. Then, gradually, I became more interested in the sciences, and in the end, I did environmental engineering as my undergraduate degree, and spent five years working as an engineer when I left university.

Q: Gotcha. Do you have any inkling of what kind of turned you in that direction?

MORGAN: I think it was really pragmatic choices about, when I left school, I needed to do something. I either needed to get a job, or I needed to go to university, or go back to school and do something else. So, [laughs] I think it was more pragmatism than anything else.

Q: Where did you go to undergrad?

MORGAN: I went to the University of Newcastle upon Tyne, which is--Newcastle is just the most northern city in the UK, just below the border with Scotland.

Q: Right. What happened after undergrad?

MORGAN: I spent about five years working overseas. Really, as a kind of independent consultant, I guess, to NGOs [nongovernmental organizations] doing water and sanitation engineering. Some of it was in a kind of development program context. But a lot of it was emergency response for humanitarian emergencies.

Q: Oh, neat.

MORGAN: Mm-hmm.

Q: Wow. What were some of the organizations you worked with?

MORGAN: The one I worked with most frequently was Oxfam, which is a large UK charity. I worked with Medicins Sans Frontieres [MSF] as well, and also another UK charity called Christian Aid.

Q: And where'd you go?

MORGAN: A little bit all over the place. Let me see if I can even remember. I think I started off in the Dominican Republic. And then after Hurricane Mitch, 00:05:00moved to Honduras. Then, I think the next thing was a cholera outbreak in Peru, and then a large cyclone in India. Then I went to Kosovo, during the war in Kosovo. So I was in Macedonia and Kosovo for quite a while, there. Mozambique, again, another big flooding event. Yeah, I think those are most of the main places I went to.

Q: Gotcha. So, that was over a period of about five years?

MORGAN: Yup.

Q: What happened after that?

MORGAN: After that, I got married. I decided that it was not a very sustainable lifestyle. I moved back to the UK, and both myself and my wife at the time decided that we were going to both start new careers. She went into accountancy, and I went into epidemiology.

Q: What year did you marry?

MORGAN: 1999.

Q: '99. Okay. Sorry, just getting all the chronology. So tell me about what happens then.

MORGAN: Then I spent about seven, eight years in the UK, and had a pretty, I guess, productive or frenetic time. I'm not quite sure how you describe it. [laughs] From that time, I spent a lot of my energy, but studying and working. I did a master's degree in epidemiology, and then got a full-time job in public health in London. Then I got onto the equivalent of the UK residency program for public health. And I also continued to study. You don't have this equivalent qualification here, but it's called a post-graduate diploma, which is somewhere between a bachelor's and master's degree in medical toxicology. Then I started 00:07:00working on a PhD, and was working and studying at the same time for about seven, eight years.

Q: Wow. What areas were you focused on?

MORGAN: I had a bit of a bipolar kind of work portfolio. My day-to-day stuff was mostly infectious disease outbreaks. I did a lot of on-the-ground investigations. But then on the academic side, I was looking at drug-poisoning mortality in the UK. Not an infectious disease area.

Q: Did you end up completing your PhD?

MORGAN: I completed my PhD. I did that in collaboration with the Office of National Statistics in the UK, which is similar to the National Center for Health Statistics in the US. I did that as a collaborative project, working with them. I finished that in 2007.

Q: Okay. What was that about?

MORGAN: That was about, essentially, how different public health measures over the last fifteen, twenty years, to reduce deaths from drug poisoning, how effective they had been.

Q: Gotcha. What happens after then?

MORGAN: Then I came to EIS at CDC in the class of 2007. And I did my EIS with the international Emerging Infections Program, and spent most of those two years outside of Atlanta, and overseas. I think in my second year, I was only in Atlanta for seven weeks, total. I spent all of my time out at project sites.

Q: What were some of those projects?

MORGAN: Again, it was a really wide collection of things. I did an Ebola outbreak in 2007 in Uganda in Bundibugyo. I investigated schistosomiasis, also 00:09:00in Uganda. I did a project with colleagues of mine from London School of Hygiene and Tropical Medicine, about different methodologies to measure mortality in refugee situations.

I did a lot of work on influenza, because I finished my EIS at the start of the 2009 influenza pandemic. I worked on just a collection of all sorts of different diseases. It was great.

Q: Wow. I think you mentioned in the interview with Mark that you led some contact tracing in Bundibugyo? Is that right?

MORGAN: Yeah. I led the contact tracing teams in Bundibugyo when I was there. I spent a lot of time out in the villages and in the communities.

Q: When you think about your time in Bundibugyo, what comes to your mind? Like what memories or images kind of surface for you?

MORGAN: I swore I would never work on an Ebola outbreak again. I got very sick when I was in Bundibugyo. And unlike the recent outbreak, there was no option 00:10:00for medevacs [medical evacuations] or anything like that. I thought that I might have Ebola, and I might end up in an MSF field ETU [Ebola treatment unit], with pretty poor prospects of coming out of it. That's the strong memory I had of it, was getting sick and worrying that maybe I had Ebola also. I didn't, of course. [laughter]

But it was a good experience, in the sense that my job was really to be out and run a list of contacts every single day. The art for contact tracing is to really get to know the people who are on your contact list. There are two facets--one is to build trust with them. By going and being the same person who's visiting them every single day, you can develop quite a good, trusting 00:11:00relationship. You'll work towards that. The other thing is that if you're seeing them every day, you can notice quite small changes in their well-being. You can see between one day to the next, if somebody's really not looking so well. So that's also another useful thing. It's a very difficult decision once you've been visiting people for a while and one of them gets sick, especially if they're a child, and then to remove them and put them into isolation. Personally, it's also a very challenging role to have.

Q: Is that something you remember in particular, having to put a child in isolation?

MORGAN: There were a couple of children, and a couple of adults, who we did isolate, yeah. And a couple of people--in fact, at least one person who had to go back in, who we suspect may have been ill with something else initially, and 00:12:00then inadvertently exposed when they went to the ETU for the first time, and then subsequently became ill with Ebola. So there are lots of quite complex situations there.

Q: Yeah, no doubt. Did you follow their cases, follow how they were doing?

MORGAN: Once somebody goes into an ETU, that's really--your job's done. You can go back to your job, which is doing the contact tracing. And it's a double-edged sword, you know, getting so close that you follow people up and become personally involved in their outcomes. It happens of course, and you are obviously worried. And then, if it's somebody from a family that you're following up, the twenty-one-day follow-up starts again, so you've got another twenty-one days of seeing the family members every day, and they ask you how that person is. So you can imagine it can be quite tricky sometimes.

Q: No doubt. Can you tell me about one person or one family, like not identifying or anything, but that you met and really felt a bond with, maybe?

MORGAN: I think some of the more kind of impactful exchanges were people who had had Ebola and survived, and whose lives had been severely disrupted by the event. I think, most memorably, a household where--I think it was the husband who had gotten Ebola, survived, and then was released, but in the course of disinfecting and cleaning--decontaminating the household, essentially, all the family had had all of their few belongings that they owned destroyed or damaged. It was kind of an interesting reminder about the impact of the disease is that 00:14:00these people were fairly destitute afterwards.

Q: Thank you for sharing that. So yeah, let's ask, what happens after '09, after EIS?

MORGAN: So, I then moved to the Dominican Republic with CDC to start the CDC country office. I was the CDC country director there from 2010 through to the end of 2014.

Q: Did you mention it was HIV [human immunodeficiency virus] that you were focused on, largely, or--

MORGAN: Predominantly. But the first thing that happened when I got there was the cholera outbreak that started in Haiti, which of course spread across to the Dominican Republic, and is often never even mentioned. But it was a major event for the Dominican Republic, which also had never seen cholera, or not in living memory. A large number of people died from it, and a large number of people were 00:15:00affected, and there was quite a significant response that we mounted with the Ministry of Health there. Clearly, the problem was much, much larger in Haiti, but there was a big problem in the Dominican Republic.

It was interesting, in the sense that we had a little bit of all sorts of different things. You had some issues with rabies. We had issues with chikungunya, which is a mosquito-borne virus that was introduced into the Caribbean in 2013. We had ongoing seasonal problems with dengue virus. We worked with the Ministry of Health on hospital-acquired infections from cosmetic surgery clinics, where people from the US would travel for cheap cosmetic surgery. So it was predominantly HIV, but we also got pulled into a wide range 00:16:00of things, being the CDC country office.

Q: How did you adjust to being in this new kind of role, as an overseer of all of the projects?

MORGAN: I think if you ask most CDC staff who have made that step from being a technical person to them being in a management and leadership position, it's a big step to make, and it does take some time to get used to it. It really requires you to pull on a number of different skills that maybe you haven't used for a while, or are not something that you would be using frequently in a scientific position. So, basic management, financial management, human resource management, then there's a whole realm of activities involving representing CDC as an agency, both to the host government, and to the US embassy, and 00:17:00engagements with the ambassador--things that really we're not normally trained for.

Q: No doubt. And so, please excuse my limited knowledge of this, but I know that one issue recently has been forced removal of Haitians from the Dominican Republic. Were you there during any of that?

MORGAN: I've been going to the Dominican Republic since 1998, so it's been an issue for decades, really. It's heated up, at the moment. But yeah, one of the studies that we did was looking at HIV prevalence among Haitian migrant workers in the Dominican Republic. It was hugely controversial from both sides, because the Dominicans didn't want to have a project looking specifically at Haiti and the Haitians didn't want to have a project that also singled out Haitians living in the Dominican Republic. It's part of the fabric of the existence of those two 00:18:00countries on that island.

Q: Can I ask, just briefly, how were you able then to navigate that, and get the study done?

MORGAN: It took a lot of time, a lot of negotiating. Again, a lot of building trust. I think the fundamental role of a CDC country director is to build that trust between the host country and CDC as an organization, and reassuring them that we're not out to score political points, we're out to look at public health issues. And even when those public health issues are politically uncomfortable, they still need to be addressed.

Q: Right. Do you remember what you found?

MORGAN: Yeah, we found that the prevalence of HIV among Haitian migrant workers in the Dominican Republic is higher than the Dominicans, the normal Dominican population. And it's also higher than in Haiti as well, in Haitian populations. That itself is concerning. Even more concerning was that very few of those 00:19:00individuals who were HIV-positive knew their HIV status. And none of those individuals who were HIV-positive, and very few of those who were HIV-negative had any access to services whatsoever. So, combined, that's a very concerning situation.

Q: No doubt. Wow. Okay. Well, I suppose we should get to the Ebola.

MORGAN: Yes. It will be nice talking about something else. [laughter]

Q: It's all wonderful. It's all good for me. So how did you get involved in the Ebola response?

MORGAN: Initially, I got a call I think back in September--August, September, asking if I would go to do a month-long deployment as team lead, I think. At that time, I was wrapping up my period in the Dominican Republic, finishing off some projects. We were actually in the middle of moving--we were just about to 00:20:00move the office from one location to another. It was kind of busy, and I had to pack up my own belongings. So I said, well, I couldn't do September, but maybe later on in the year. And then, as time went on, more weeks went on, CDC came back to me and asked if I would go and help establish the country office in Sierra Leone. Then I had quite a lot of encouragement from my new supervisor, here in Atlanta, to go and do that. So I said yes.

Q: Can you tell me who that supervisor was?

MORGAN: Toby [L.] Merlin.

Q: What were your thoughts going in?

MORGAN: I tried to keep an open mind about it. I thought I would go for maybe three months. I thought two, maybe three months would be long enough. I didn't 00:21:00think the situation was anywhere near as bad as it was. So I was a little bit surprised when I got to the country to see how bad things were. I also had no idea that it was going to become such a large deployment for CDC.

Q: No doubt. So, you gave in the previous interview with Mark a really great timeline of the CDC's response in Sierra Leone from your arrival as country director, through about, I suppose, the Campaign to Zero in early 2015. I'm wondering if, looking back on that fall period, when things were really awful, if you have any specific memories that surface for you as important?

MORGAN: When I got to country, the first thing I did was spend two weeks traveling around to see what was going on, on the ground as it were, and spending time with our teams, who were working in the districts. I'm glad I did that because once you get engaged with what's going on at the national level, then it's very difficult to find the time to get out to the field to see what's going on. That was when I realized that things were really very, very bad, for a start, and also very difficult for our staff. In my mind, I think of it in the sense that, at that point, we had an approach--like a World War I approach of sending as many people at the problem as possible, and I knew then that we 00:23:00needed to get to something more like an intelligence-led approach, which you would see in a kind of modern warfare type setting. And that just sheer numbers were not going to help.

The month before I traveled to Sierra Leone, I was listening to the weekly calls with Dr. [Thomas R.] Frieden from Sierra Leone, just to get some background and a sense of what was going on. It was clear to me when I departed from Atlanta that those weekly calls each week, the reports about how the response was going, was more and more positive that the response was getting better and better. But that was at odds with what was going on with the epidemiology, which was getting worse and worse. So before I got there, I knew that there was something a little bit amiss with the perception of the response than the actual impact that the response was having.

The first two weeks was really about me seeing what's going on, on the ground, and what kind of situations our staff are working in. And then, the event that really sticks out in my mind as a kind of a turning point for me from being fairly confident about what we were doing to being very concerned about the situation was a meeting convened by the president of Sierra Leone. All of the ambassadors from the main bilateral partners were invited. I accompanied the US charge d'affaires. She asked me to go with her as a kind of a technical advisor to her at that meeting.

The president gave some opening remarks, and then asked each of the ambassadors, 00:25:00in going around the table, to give their opinion on the situation. This was the end of November or mid-November, maybe. Let's say mid-November, 2014. And the comments from the ambassadors from the main partners countries was astonishingly off-the-mark. People were saying, "We'll be finished by New Year's Eve, by Christmas. We'll get on top of the situation. This isn't anywhere near as bad as people are saying," and things like that. And it occurred to me at that point that people were not at that point prepared to openly admit the gravity of the situation. That's when I realized that we were heading for a bad outcome--if we 00:26:00couldn't, even amongst ourselves, in a closed room, talking with the president of the country, give a realistic summary of the situation.

Q: You mentioned that was a bilateral meeting. Government officials obviously were there, but also partners like CDC and others?

MORGAN: No, it was really country partners. So, the UK, China, US, and some other countries who had diplomatic missions in Sierra Leone.

Q: Gotcha. Okay. Yeah, that would be striking. [laughs] Any other memories of setting up the Western Surge, for instance, that stick out to you?

MORGAN: After that meeting with the president, I had several follow-up 00:27:00conversations with the US ambassador [John Hoover] and his team, and also some follow-up conversations with Dr. Frieden, to say that we really needed to communicate the public health seriousness of the situation in an either more striking way, or a more effective way, but that the response was too slow, people were too relaxed about the situation, too optimistic about their abilities to change the course of the epidemic, and we really needed to turn up the intensity of our response. So the US ambassador, along with myself and some members of his team, we met with the equivalent of the incident manager for Sierra Leone, who was [Alfred] Paolo Conteh, who's the minister of defense. At 00:28:00that meeting--and prior to that meeting--but at that meeting, I suggested that we needed to really stop the increase of cases in the Western Area. Because that was turning into a major problem. We knew that in Liberia, Monrovia became really like a vessel for the transmission, and then we would be spitting cases out to other parts of the country. But in Sierra Leone, the situation was different. There was widespread transmission in many districts, and we were just unable to fight multiple fronts and take on a huge urban Ebola outbreak. I think we were at a point where we were just about to be overwhelmed. So I discussed with him, made some observations and recommendations that we really needed to increase our activities in the Western Area significantly. This was our final 00:29:00front, and if we lost this line--sorry, a lot of war analogies. But it was fairly war-like. If we lost that line, that front, then we would be in real, real trouble.

That had a mixed reception. I think there was also a general sense that the situation wasn't quite as bad as I was painting it out to be. A few days later, I was again out in the districts, I got a phone call from one of the senior UK leadership to say, why is CDC spreading rumors, or effectively causing trouble by saying the situation is out of control when that's probably not the case? I 00:30:00mention it only to say that it wasn't clear amongst the response team as to where we were in the situation.Anyway, the bottom line was that, after some further thoughts and deliberations, on further conversations, that people suddenly realized that we couldn't take this in such a relaxed manner, and that we needed to speed up our activities.

Q: Great, thank you. Memories of conversations or decision points, etcetera, that come after that?

MORGAN: I think for me, the main issue was around beds. I think I probably said "beds" a million times daily for a few weeks. From my experience previously working on Ebola in Uganda, there are lots of components to an Ebola response. 00:31:00But the most fundamental one is being able to isolate individuals from the community and stop them infecting others. We simply didn't have anywhere near the number of beds that were needed in Sierra Leone. I went to the main hospital, the largest hospital in Sierra Leone, and the only one that stayed open throughout the whole outbreak. And people were dying in front of the hospital. I've been through many, many different disasters around the world, and you rarely, if ever, see people dying in front of you. That's a catastrophic kind of disaster.

I think a very subtle but important issue was that most people in the leadership positions from either the Sierra Leone government or other governments or organizations were expressly told not to get close to anybody who might have Ebola. That was no different from the US, but that was really the sentiment from 00:32:00a lot of the partners at the time, was for the leadership to not get too close. While it protected the leadership from potential exposure to Ebola, it also prevented them getting out there to see close-up and personal what the situation was like. And I think that fed into the false sense of security, or difficulty in assessing the gravity of the situation, is that they were not able to get out there on the front line and see it for themselves.

After all of those events, I remember having a particular conversation with Dr. Frieden. I think he called me, or did I call him? I can't remember. But essentially, saying that we were not getting enough beds quickly enough, and 00:33:00that we needed to do more, and we needed to push harder, both from a technical perspective, but also the USG [United States government] needed to push harder from a political perspective, to do whatever we could do to encourage our partners to get beds in place quicker.

Part of that work to do that was me working with Martin [I.] Meltzer and his modeling team here in Atlanta to come up with some estimates of what would happen if the response carried on at its pace that we had set. There were dates for producing beds, or providing beds starting in January 2015, maybe February 2015, and we were still in November 2014, with a number of cases that was exceeding our capacity to even test people. Martin and his team did a very nice 00:34:00model showing that, if we delayed the opening of these beds by a week, the outbreak would continue to exceed the bed capacity, if we carried on in this trajectory. By the time we got to January 2015, there'd be so many cases that the number of beds that were going to be available were still not going to be enough.

So, we got as much technical argument behind us as we could, and then I asked the US ambassador to essentially arrange a meeting with the UK leadership in Sierra Leone. The UK had taken on a lot of the work of getting the beds. Not exclusively, but largely. And we kind of made our case, and said, we really need to--instead of do this in six weeks, do it in three weeks, which was a major challenge for them, for sure. There were a few other pivotal moments in that 00:35:00short period of a few weeks. And the other one was that the Ministry of Health [and Sanitation] of Sierra Leone actually opened up its own ETU. PTS-1, Police Training School 1, yes. It was an ETU based on the site of a police training academy. And that was hugely important. And they opened that up very quickly.

The other one was MSF. And I remember meeting with Joanne Liu, who's the international director of MSF in Freetown, I think towards the end of November, beginning of December. Because they were similarly very worried about the situation. I impressed on her the importance of getting as many beds open as quickly as possible before we lost complete control of the situation. From that conversation until them setting up an ETU and getting their first patient in 00:36:00Freetown was something like--I think it was like fourteen or twenty days. I mean, it was an incredibly short period of time. And they also did a lot to help alleviate the bed issue. Then, when a lot of the beds did become available, thankfully we had seen some decline in the number of cases.

The Western Area Surge--I actually can't remember in detail how the whole thing happened and how it started. But one of the driving forces behind the surge as a campaign rather than just an increase in activity was done by somebody called Yvonne Aki-Sawyerr, who is a Sierra Leonean who had grown up partly in the UK and was part of the Sierra Leonean diaspora. She was working with the national 00:37:00coordination body at that time. She helped galvanize a lot of the thinking and planning and preparedness for what turned in to be the Western Area Surge.

Q: Wow. What organization was she with?

MORGAN: She was initially on contract with the UK, and then I employed her after that. [laughs] I gave her a contract. But she was essentially working on behalf of the National Ebola Response Center, the NERC.

Q: Gotcha. Thank you. And so, I suppose we go into about 2015 now, and to the next phases, the Campaign for Zero?

MORGAN: I think that--I mean, there were a number of other key things that happened for the Western Area, which--

Q: Oh, sure.

MORGAN: --just to finish that off.

Q: Oh, please. Yeah.

MORGAN: There were some other key players--[Colonel] Andy Garrow, from the UK military; Victoria Parkinson, who's a UK civilian working with the [Tony Blair] 00:38:00Africa Governance Initiative, which is an NGO; Desmond [E.] Williams from CDC, who was heavily involved in the surge and planning. Essentially, we just took every aspect of the response and doubled it, and halved the timeline for us to deliver on it. That was not just beds, but lab testing. It was the alerts. It was the contact tracing. The surveillance teams on the ground. The number of ambulances. We had to create a whole system for dealing with maybe one hundred ambulances, and disinfecting them daily, and all of the water and the PPE [personal protective equipment], and everything that was involved. Just 00:39:00logistically a huge feat. And also increase in the number of burial teams.

The whole thing was just a logistical huge, big push. I think the president himself was closely involved in what was going on. We were meant to start--my dates might not be exactly accurate, I have to check them--but I believe we were meant to start on the 15th of December and we essentially presented to the president to say, this is where we are today. And he said, you're not ready. They were going to start on the 18th, I think is the day we actually started. And in those couple of days, it was enough to get us ready. I think that was the right decision to make, but a difficult one at the time. It was a period in which, as we got to the point of launching the surge, it became apparent to me 00:40:00that we had put into play all of the assets that were ever going to be available to Sierra Leone at the end of 2014. Nobody was able to provide any more personnel. We couldn't fly in any more ambulances, vehicles, equipment. Internationally, there was nothing else that anybody could do. We had really pushed all of our capabilities into action. This was a kind of Custer's-last-stand-type situation, in that it was all-in, all our chips were on the table, and this was going to be the make-or-break kind of situation.

Q: Thank you. So, memories after that?

MORGAN: I think in January, when we saw the cases coming down, there was some 00:41:00sense of relief. Again, ongoing communication challenge about what that actually meant. People were very focused on case counts, but then, really a more nuanced assessment of the situation was needed. The fact that there were ongoing changes in transmission in multiple districts occurring at the same time was hugely concerning; that our ability to do contact tracing was limited, if not nonexistent in many places; that our ability to keep up with all the testing that was needed, and all the burials, and things like that was still struggling to keep up. It appeared--I mean, if you look at the graph of the number of cases by week, it looks like there was a big drop-off and things were okay. But we 00:42:00were still dealing with a huge Ebola outbreak every week, and there were like over one hundred cases each week. Which is unimaginable in normal times, or previously. But at that stage, people were relatively blase about it, and thought we were on the right road.

I think what is often called the "shoulder," which is this long period from January to March, where the case counts really don't go down, they just remain the same, reflects how difficult it was to maintain the intensity across seven, eight districts, all at the same time. But it also reflects, I think, maybe a slightly premature withdrawal of some of the efforts. And there were also some 00:43:00other extenuating circumstances going on. But I think that many people were a little bit misguided about the fact that just because it came down once didn't necessarily mean that it would continue to go down. As we saw, actually in Sierra Leone in May, the number of cases went up, and there was quite a big cluster of cases that occurred around May time. It was a very difficult period to--everybody was exhausted, and it was a difficult situation to be giving maybe not good news.

Q: No doubt. So, for example, what were some of the resources that were being pulled back? And by whom?

MORGAN: I think, rather than resources necessarily being pulled out, there was 00:44:00probably less rapidity in some of the responses, or less urgency, and the pace slowed down a little bit. Maybe some funders took longer to make decisions, or some NGOs moved a little bit slower than they might have if--or they were moving with the situation was quite acute. I think there was just a general slowing-down, rather than a particular pulling out.

Q: Sure, sure. So what happens after that?

MORGAN: Well, we're getting into April and May. In May, there was a key event that happened in Port Loko that--there were a couple of chains and a couple of individual cases that occurred, which really seeded the Ebola outbreak between 00:45:00May and the end of the year. And it can mostly be traced back to one or two individuals and chains that occurred in Port Loko and Kambia. By April, May, the situation in most of the other districts was fairly under control, and the outbreak had really become limited to three districts, which were the Western Area district including Freetown, Port Loko district, and Kambia district. There was a lot of community resistance and difficulty in accessing the communities that were affected. So it became a different kind of response. It needed to be much more like a traditional Ebola response. And we were able to switch on what we do normally, so the contact tracing and careful follow-up of cases.

Q: Gotcha. Any conversations you remember having around then, or subsequent?

MORGAN: There were lots of conversations which maybe could be broadly categorized as issues around the quality of our response. When you're getting down to the lower numbers, and the more refined aspects of the response, every issue of quality is important. There's a very small margin that you have to make mistakes. I'm not quite sure when it happened, but maybe it was a gradual slide from being able to have fairly open and frank conversations with some of our key partners when things didn't go well, to one of some defensiveness about, well, 00:47:00you're trying to blame us for something that's going wrong. Partly because of the extreme fatigue that there was in some of the key responders, who like me, had been there far too long, quite frankly. And also, other political pressures. I think especially from WHO [World Health Organization], which was trying its hardest to recover from the difficult period it had in 2014. It wanted to be seen to be succeeding. But that can create some other competing tensions within the response. I would say, more than anything, that period was about rigorous attention to detail, and lots of difficult conversations when things didn't go right.

Q: No doubt. Tell me what happens next.

MORGAN: Well, then Sara Hersey arrives as the permanent country director, and I hand over to her, and really put my attention mostly onto the science portfolio. Amongst all the other things that were happening, we also were trying to do some fairly ambitious science work. We had the STRIVE [Sierra Leone Trial to Introduce a Vaccine against Ebola] trial, which is obviously the biggest, and probably the best known of the CDC's science projects. Maybe it needs another hour in its own.

Q: [laughs] Yeah, I'm sure.

MORGAN: And that had some pretty exciting moments, especially before the launch of STRIVE. You might have spoken to Jane Seward about that.

Q: I did, yeah.

MORGAN: But we also had other important projects, such as the Household Transmission Study that happened in January to March in Sierra Leone, looking at 00:49:00household transmission dynamics. Critically important was the Virus Persistence Study, which we started--I think in the end, it was about June time, to look at how long Ebola virus persist in body fluids of survivors. That has given us really a unique insight into what the situation is, and anticipating--although we didn't foresee it, but we anticipated that there would be a problem down the line, with so many Ebola survivors, and the possibility of new cases occurring unexpectedly. But we didn't know how long that risk would last for. So this was, I think for me, one of the more important studies that we did.

We also helped NIH [National Institutes of Health] do their ZMapp RCT [randomized controlled trial]. Again, that would probably take another hour for me to go through some of the roller coaster of that experience. But that was 00:50:00also a major challenge.

And then, some of the other things that we haven't spoken about, but I'm sure you have had from others, is the staff exposures in the Port Loko Partners in Health incident, and things like that.

Q: Actually, I haven't heard too much about that. But we--

MORGAN: We might have to--

Q: --given our limited time, we might--

MORGAN: Right. We might have to do that at another time.

Q: Sure.

MORGAN: For me, at least, from July--June, July, August, my contribution is best characterized in two pieces. One is trying to get as much of our scientific work advanced and organized as possible. And the second was anticipating coming back here to be an incident manager, spending quite a lot of time traveling to 00:51:00Guinea. I think I went there five or six times in the end. And also traveling to Liberia, to become more and more familiar with the situation in those two countries. But Guinea, I got out to almost all of the prefectures, apart from the Forest Region, where there were ongoing cases.

Q: Right. And this travel is happening in about September?

MORGAN: No, no. This was happening in, like, June, July--

Q: Oh, June, July.

MORGAN: --time. Yeah.

Q: Gotcha.

END