Global Health Chronicles

Dr. Satish Pillai

David J. Sencer CDC Museum, Global Health Chronicles


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Dr. Satish K. Pillai

Q: Hi, this Sam Robson here with Dr. Satish Pillai. It is September 19th, 2016, and we're here for our second interview as part of the CDC [Centers for Disease Control and Prevention] Ebola Response Oral History Project. We left off last time toward the end of Dr. Pillai's deployment in Liberia toward--you know, middle of August. I was just going to ask him to describe some of the people he worked with who were Liberian. And he mentioned a Luke Bawo.

PILLAI: Yeah. Luke was the--when we had gotten to Liberia, he essentially was our reference point for all the surveillance activities that were happening at the Ministry of Health [and Social Welfare]. I guess more than anything else, I identify him as the person that we probably interacted with most frequently, although there were many other people. But our initial purpose was to go in there and help with surveillance activities, help with the Epi Info viral 00:01:00hemorrhagic fever module. Thinking back on it now, I guess that's why he's the one that sticks out in my mind as the point of contact. And whenever, going to the Ministry, there were other people there. There was the minister of health, the deputy minister, the person that eventually became the incident manager, Tolbert [G.] Nyenswah. I met and interacted in some way, shape, or form with lots of these folks. I guess it speaks a lot to how you frame your deployment, in your mind, what you think you're doing when you're going there. Even though we ended up doing so many different things, that was who, in my mind, at least now that I think about it, Luke was the person that was, in my mind, representing the Liberian--the person that I would think of in Liberia when I 00:02:00think about that first deployment.

There were other folks that we would interact with. I think we had talked about visiting the national call center and the staff there and how they were basically working 24/7 [twenty-four hours a day, seven days a week]. And in such, you know, very small, cramped corners at the John F. Kennedy Hospital in Monrovia. And going out to meet the county health teams in Bomi County, in Margibi County. But again, coming back to my day-to-day work was making sure our team was operating. There was a lot of interaction with the EIS [Epidemic Intelligence Service] officers on the team, other staff that were coming to our team, and our team lead, and just coordinating all those activities, working 00:03:00with the embassy and then starting to work with some of our US government partners that were either already there, like at the embassy, and coordinating with--some of the things sound mundane, but it still sticks in my mind. Coordinating with motor pool every day, and starting with--you know, we have this person going here and this person going there, and we need this many vehicles. It was not something that I envisioned having to do, but that's what I ended up doing every day for quite some time until we got additional support and we got a system in place.

And similarly, working with NIH [National Institutes of Health] partners that were helping stand up some of the diagnostic testing for Ebola at the national reference laboratory that was about an hour outside of Monrovia. Just walking 00:04:00through a system for accessioning laboratories, and how clinicians or the health department might want to get the results back to them and thinking those processes through, and then also meeting with the USAID [United States Agency for International Development] DART [Disaster Assistance Response] team. I remember several conversations and meetings with their staff. They had a USAID person on the ground, Justin Pendarvis, who we spent a lot of time talking to before the rest of their team arrived. And then after they arrived--what was his name? Was it--it was Tim--I'm blanking on his last name now, but he was--I remember, very different than the CDC, the USAID team came with their--outfitted with USAID labels and USAID patches. They had essentially a uniform. You knew 00:05:00what they were and who they were, and who they represented. And we were kind of in our--just field clothes. It was a noticeable difference. They were great to work with. They came in, they wanted to know what the situation on the ground was, and our teammates and team members were able to spend a lot of time thinking, these are the things that we've identified as needs. It was great to see more support coming from the US. I remember feeling really optimistic, like a couple of days before leaving, having that press conference, where there's a small number of local Liberian press that were in the US embassy, and the DART lead was there, and Kevin [M. De Cock] wasn't able to do the press conference. I 00:06:00sat in, and their questions were like, what does this mean and how can--you know, what do you think is going to happen, and how can you help? I felt very reassured to know, like, I felt like the US government was going to do something. Because we were sitting at the embassy, the DART lead was there kind of as a representative of, you know, we know this is a problem and we're here to help. And I felt more confident saying things like, the CDC is here to help identify the cases and track--you know, help you with your active case finding, contact tracing. There's these issues of infection control and being able to care for individuals. These were the issues that needed to be sorted, and I felt 00:07:00more confident knowing that there were potential resources that would be brought to bear to get to those issues and address those issues.

Q: So is that the point? Or where is the point where you start to feel like, okay, now CDC is starting to get it? Like, our initial mission, which they kind of didn't understand wasn't possible, because none of the data was here to actually do, like, the Epi Info, etcetera? They're starting to get it now?

PILLAI: It was an evolving thing. I think there was a level of maybe people didn't appreciate--maybe they did, maybe they didn't, I don't know. But what I felt was, like, some of the questions they were asking, I didn't feel like everybody fully understood. I remember we would have team meetings where Kevin 00:08:00would ask, "Do you think Dr. [Thomas R.] Frieden should come out here and see this?" And I remember saying "Yes, I think that would be a great idea," because you can see the clear magnitude of the problem and how this is beyond just simply graphs showing increasing numbers of cases. This is causing devastating effects for an entire society. Schools are closed, and I think the borders were closed, and there was curfews. Some hospitals were shuttered, and people refused to either go to work or people wouldn't go to hospitals because they were afraid of getting infection. There was a perfect example of a sign at the Ministry of Health. It said that vaccinations weren't being held because of concerns of the 00:09:00risk of Ebola transmission. I was like, this is horrible. Vaccine-preventable illnesses are now potentially going to increase in the coming months because they're stopping one of the best preventive mechanisms, methods that we have for preventing disease. You're seeing all these things happening, and it was so much more meaningful than just reporting numbers. So it was like, it will be great and it would add a very senior, credible voice to the rest of the international community, saying this is important. And I think he ended up coming out I think a few days after we had left. I felt like it was starting to sink in, because the teams that were coming in after us were getting larger. And, like, when we 00:10:00were--as we were rotating out, it was clear that the--the second team that was coming was much larger and had a different complement of people. Like, there was staff that were specifically being assigned to be the liaison to the DART team. And some of that was just so, you know, people were communicating with one another, but I think it also speaks to the fact that we knew that this was more than just setting up a database for tracking cases.

Then even after I got home, once I got home in August, I went to the EOC [Emergency Operations Center], and I was trying to figure out how I could continue to support and help. I was working on the training course for--initially, I don't know, it was just an idea. It was like, somehow getting 00:11:00clinicians out there to do work. To do that, they need to know how to work in an Ebola treatment unit, and what does that mean? How do they keep themselves safe? Eventually, it turned into this training course for healthcare worker safety and how to put personal protective equipment on and off safely. It ended up being run in Anniston, Alabama. I remember early on trying to explain to people, like how in the EOC, this is how--this is the situation on the ground, and some of your assumptions--like, I think a very concrete example at the time, while they were still trying to figure out how this vision of getting more healthcare 00:12:00workers overseas would work. They were standing up more and more teams in the EOC, like infection control teams, international, domestic, and this training course idea. I think it was the international infection control team [that] focused on Ebola treatment units. There was a person on the team that asked me, do you think it would help if there was a door, you know, an Ebola treatment unit to keep suspect patients in--because there was some question that had come up about how they felt like patients were just kind of wandering around in--and suspect people were mingling with confirmed cases. It just jarred me. There's just not even a real realization of, like, what do you mean a door? Should we install doors? Some of these places were just tarps and--and just, things that 00:13:00were just--just artificial divides that were--there's no door that you're going to screw into a doorframe. It just struck me as a disconnect. It's like, you have to see some of the locations that you're working in. And it's like, you're making do with either an existing structure and trying to refurbish it, or it's a tent structure, which is what ended up being put up. This large tent structure was put up by MSF [Medecins Sans Frontieres] right across from the Ebola treatment unit that--ELWA [Eternal Love Winning Africa hospital] Ebola treatment unit in Monrovia. They built a third ELWA Ebola treatment unit, which had several hundred beds, which quickly filled up within days. Maybe even the first 00:14:00or second day, they were at capacity. But just, there was this disconnect when I got back. It's like, oh, it's not like here, it's not like a healthcare setting here. Just having those types of conversations, I felt like sometimes a broken record. It's like, I don't think that you understand the situation on the ground. What was personally helpful for me, I think it was the end of August 2014, Inger [K.] Damon was the incident manager. She'd asked for an update on what was happening in Liberia. I was there in Atlanta, Kevin was in Nairobi because he's the country director in Kenya. She asked if we could do the 00:15:00presentation, and so then I was going to do it. I remember asking, "What are you looking for?" I was like, "Are you looking for data, or pictures?" So she's like, "Pictures are fine." I asked the team, send me whatever you think we should to make a compelling argument for what's happening. Personally, it was good for me, because I was able to create a presentation that portrayed a really stark image of, like, people are dying. There's terrible things that are happening, and you just don't appreciate from looking at bar graphs and epi curves.

Q: Those are the kinds of things that were pictured in the photos?

PILLAI: Yeah. It was an IM [incident manager's] update, or I don't even remember 00:16:00what it was. I just remember the room was packed. In retrospect, now that I've been in the EOC for as long as I have, maybe it was an IM update. But every seat was full, and I remember presenting. It was, like, a twenty-minute presentation of just the--initially, it was a couple of maps just showing, this is what the epidemic reportedly looked like based on case counts in Liberia when we got there, this is what it looked like when we left. Increasing numbers of cases. And then I was like, but this is what it means to us on the ground. And I showed these really small treatment units that had people all outside trying to get--waiting to get in. The two Ebola treatment units. Pictures of the hospital where our team saw nurses chasing after--or running after an Ebola patient. A 00:17:00known Ebola patient who had basically gotten out of their hospital room. They couldn't get him to a treatment unit, I think was the scenario. And you see the person walking down the hall, and a nurse going after them in full PPE [personal protective equipment]. They're potentially infectious, their PPE is contaminated. And a picture of an infant that was left unattended because their parents had both died. People--you know, there were dead bodies on the street. Just telling people that this is what we are seeing, we saw. And then I also made the point, I guess it was ten days after I had left, and I was like, I don't want to make any--because one of the most frustrating things was trying to express what you were seeing on the ground to people in Atlanta at the time, because they were so disconnected. I made the point, it was like, almost 100% 00:18:00sure I said it. It's like, "And I'm not there now. Things have probably evolved even more since I was there, and the people on the ground can clearly articulate the concerns and problems much better than I can." Even just a short period of ten days can--things can evolve really quickly. There are infection control problems. There are problems with supplies. And just pictures of how they were taking care of their PPE. It's just washed in tubs outside of the Ebola treatment unit, and hung to dry on clotheslines. It's not Western, US, medical standards. So it was cathartic for me to kind of be able to express this. I remember, I brought a couple of people that had deployed with me, Ben [Benjamin 00:19:00P.] Monroe and Jennifer [C.] Hunter and Almea [M.] Matanock were there, because I figured they should be able to weigh in as well. After I finished, there was silence for a good while, because people were just trying to, I think, process all this information. Many of them may have known, and they heard, but it was a good way to help reframe or just--frame it through our eyes. Like, this is what we saw. It was meaningful for me, and I think for my team, and I think for some of the people that attended that briefing. Somebody said that this may help change the trajectory of how we're doing things. And I don't think that it 00:20:00necessarily did. I think things were already moving that direction. But it was--again, at a minimum, it was helpful for me to be able to express what I felt.

Getting back to your original question, I don't think people got it. They were starting to get it, and then more and more and more people started going over. I think by the time I went over the second time, people got it. It was a much clearer picture, and I was just itching to go back. Get the training course done and get over there as quickly as possible. The training course was--at the time, 00:21:00I didn't think much of it, but I ended up seeing several of these people on my second and third deployments in Liberia. It's like, wow, this training course actually--there are people that I--I saw you. I helped in some small way. It was meaningful.

Q: Did you get feedback from them about the course?

PILLAI: A couple people that I would--that I saw going back over, they were really grateful that they had done the course. At least one of them was like, it really helped provide context of what we'd be doing. It was weird because the course itself, there's great ideas and curriculum, but it has to get done in this really--I think the first course, the pilot course might have been on 00:22:00September 20th, 22nd, something like that. Within four to five weeks, there was a binder, a syllabus with lectures, and presentations that were given, PowerPoint presentations. The week prior to that, I remember going out to Anniston. Some of the more--the team leads had gone out and talked to the FEMA [Federal Emergency Management Agency] people about setting up the course. Working with them on getting the grounds to work on. Then just the operation of, what are we supposed to do here? I remember going there with an EIS officer, Rupa Narra. I think it was literally a week before I think the course was start--the pilot course. It was September 15th or something like that. We're 00:23:00talking, and we're sitting in the conference room and talking about what we're envisioning. But still, where are we going to do this? They had some office space, old buildings that didn't have anything in it. The doors were locked and had chains with a lock on it. And they said, you can use that space. It was a pretty dreary looking space.

We were just talking about this. Finally, I was just like, do you have chalk? I just remember that there were these large buildings that were off maybe a quarter mile at best away from the main FEMA training course area. You drive down this gravelly road, and there was this large field, and then it led up to these old buildings that were probably from the 1950s or something like that. 00:24:00There were two large buildings, and there was a large walkway that went around the entire perimeter of both buildings. It was paved, and columns supporting the building every so often along this walkway. I was like, we have to create an Ebola treatment unit for people to walk through. I remember getting on my hands and knees with the chalk and just starting to draw, okay, this is a suspect area and this is a suspect bed. This is another suspect bed, and here will be some tape that delineates a suspect versus the probable, confirmed side. This is the flow from low risk to high risk. We start on the outside, and then we weave into the inside of the building. We'll put all the personal protective equipment where people get ready in here.

I remember sketching it out on the ground, and like a week later, I think the 00:25:00Monday or whenever the course was supposed to begin, teams had gone there on a Sunday, and they started laying out the cots for the beds, and they got dummies from FEMA because FEMA had dummies. They'd laid them out, and they got the orange, plastic fencing to separate the perimeter from the outside to the suspect side, and between the suspect and the probable side. Huge tanks full of water, which are supposed to simulate chlorine wash stations. I remember coming back and saying, wow, this actually looks like some of the pictures of the places that we saw in Liberia. Then we had some MSF colleagues. What is it, Mary 00:26:00Jo [Frawley] I think was her last name, [Frawley]. She provided that real-world, this is how--she had spent time in multiple, I think, viral hemorrhagic fever outbreaks for MSF. I think she had spent some time in Sierra Leone. She helped provide some additional, kind of, reality setting for the treatment unit. People that went through it, they felt like they--after the fact, they were like, it helped simulate a potential environment that they would be working in. We had blood-draw stations where you had to try to draw blood from these dummies wearing full personal protective equipment, you know, the gloves, and they had to transport patients from the grassy knoll that was outside the building that had come to their triage station, and how to get them into the treatment unit 00:27:00wearing their PPE, and how to do all this safely. How to take the personal protective equipment off and get sprayed with, you know, as they were doing this. It was interesting, and I think it was helpful to--at least, a few people that I spoke with, when I met them on the other end, I think someone did a survey, one of the--I think Rupa did a survey. You could probably talk to her about what their assessment was of the utility of the program. But I know from an anecdotal couple of people, they saw me and had a huge grin on their face. Even though you weren't supposed to hug people, we might have hugged. [laughter] Everyone there was, like, the elbow bump. But it was really personally rewarding 00:28:00to know that maybe in some small way, this helps get more people out there.

By the time that--like, when the course training started, I just want to figure out [how] to get back over to Liberia. By the time I was done with the course, I felt like this was something--I take pride in having participated in this work, and I felt like I was--and I was even that much more ready to go back. By early November, things were falling into place for me to go back. I had my dates. I think I went on Veterans Day, 11/11 [November eleventh] or something like that, 2014. I was there for six weeks, November through December. Each deployment was different for me. That second deployment was the one that I had the most varied 00:29:00experiences. I was very much in Monrovia, and just went out to Margibi [County] and Bomi [County] that first deployment. Probably just getting my bearings more than anything else, that first deployment, helping with their IMS [incident management system], helping coordinate the team. Probably helping myself just understand, what am I doing here? That second deployment, I remember, all I could think of was getting off that plane, getting to work. It was a different route. We flew through Casablanca, and I remember one of my colleagues, one of the EIS officers that I deployed with the first time, Joe [Joseph D.] Forrester, 00:30:00was on that trip with me. We were both just ready to go.

Getting off the plane at Roberts [International Airport], I was so excited to be back, and I wanted to do anything just to help. You just got off the plane and you knew what you needed to do. It was so routine. It was like, get my stuff, get to the embassy vehicle. We started driving, and it was like 3:00 am or something because when the flight got in, and rolling through places that we'd been through--it was very different because I think the curfew was still in effect, and it was very quiet. There were some checkpoints we went through. Got to the hotel, checked in, laid down for like an hour. Then it was like, emailing, where do I report, what do I need to do? Let's get to work. I remember 00:31:00people saying there's plenty to do, don't worry about it.

I think because we were returning deployers, there was a need--at this point, the outbreak had started changing. This is now November, and they were starting to see these outbreaks occurring in rural villages, sometimes linked with the person that had come from Monrovia and went back to their home village. There's links somehow to people coming from one location potentially going back to their home to--when they were ill, for care, or something to that effect. They were in some pretty distant places, and teams were going out. Both Joe and I were just raring to go. It was within days, I was going to Rivercess County, which is on 00:32:00the southeastern part of Liberia. There had been an earlier team that had gone out because there were some cases that had come in from Grand Bassa [County] to a remote village, Gozohn in Rivercess. That was kind of northwest part of Rivercess County. Then they come back, and they needed another team to go back in to do the active case finding and contact tracing. I remember driving out there with a team of three. There was a big--a medical anthropologist, Romel [S.] Lascon. Or I think it's Lacson. Jose [E.] Hagan was an EIS officer at the 00:33:00time, now he's on staff. We went to Cestos City, which is the county seat, and met with--this was the early phases of the Rapid Isolation and Treatment of Ebola strategy. It was meeting with the county partners. The county health department, the partners like the Red Cross and UNICEF [United Nations Children's Fund] and MSF and all the clinical partners and other folks. What are the resources this community needs, and how are we going to get it to them? I remember the meetings at the health--with Wilmot Smith. I think he was the county health officer. We discussed what was happening. But eventually, you have 00:34:00to just go. So we drove up, and it was a several hour drive through these--they're not really roads. They're just dirt. And huge potholes, and you're driving for hours on end. At one point, we--the embassy driver rolls down the window and asks a passer-by, "Which way to Gozohn?" It was this back and forth, I remember. The guy's like, "Gorzon?" And he's like, "Gozohn." "Gorzon?" "Gozohn." Eventually, he's like, yeah. Then he points in one direction. Then we start driving, and eventually, we're just driving in these reeds and tall grass. It was clearly--we were not going where we should, because it was--and so then we'd turn around, and then we asked another person, and they're like, "Oh, you mean Gozohn?" [laughs] So we end up--but that was--there's no road signs, there's no nothing. We eventually got there through bridges that were 00:35:00essentially logs. And trucks that were stuck in mud. But we roll into this village, and everyone is very--they need us, and we had a long meeting with the village elders asking why we're there.

At that time, there were--I can't remember if he was a confirmed case, or he was a probable case. But there was a family that they had--there was many people that had died in and around this village. There was a husband, wife, and a child that had run away, and they were hiding in the bush, and then they came out. The village immediately knew that they were potentially infectious, and they had them basically isolated in a house off to a part of the village. I remember we 00:36:00went to the home, and we were outside the--and the husband was on the patio, and he just looked miserable. Just looked unwell. The wife was basically caring for him, and there was a small infant that she was holding. It was this infection control nightmare. If the infant and wife weren't sick yet, they were at high risk. She was laundering his clothes. He looked quite unwell. Who's feeding him? Is he getting clean water? How do we get him these supplies without potentially contaminating other people? I remember, we were trying to come up with temporizing measures to make sure this person gets appropriate care while--because there's no other resources there at the time. MSF was coming up. 00:37:00I think they were--they came up the next day, and they started building a temporary treatment facility, which they were putting up really quickly. It was really impressive, and I'm pretty sure the--I believe the husband ended up being positive for Ebola. I don't recall if the two others were. I think the child was not, for sure. And then other people are coming to the palaver hut where the meeting was being held. They were unwell. Do they have malaria? Trying to triage all this, and figure out what the needs of the community were. I think this is the community that also--the goal is to--you don't want people to start going off into the bush and potentially spreading Ebola beyond even this location. I 00:38:00think it was this community where there was a broken water pump. What are the things that could help keep people in the community? Isolate the people that are ill until clinical services can even be brought to them, or they can be safely taken out. That was a component of the RITE [Rapid Isolation and Treatment of Ebola] strategy, providing appropriate resources like food. They needed water. So identifying that as something that this community needed somehow, like a repair of their water pump. I'm pretty sure that was the community where that was something that we took back. We need to get them water, a way to get water. The RITE strategy, it was a way to see how it worked. You bring the resources to them, the affected community. You try to keep people from reaching out in an 00:39:00uncontrolled fashion where you could potentially spread infection, and provide these temporizing measures like separating potentially infectious people. But ensuring that they get food and water. And this was all happening while MSF was standing up their services. It was really interesting to see how they operated and how efficient and resourceful they were.

We stayed overnight there, and then I remember our team lead came out. I'm trying to remember how this--in Rivercess, we went up, then I think we came back down to the county seat. Then did we drive back up? It's hard to believe I'm 00:40:00starting to forget some of this. But we were there at least for a couple days. I remember at least spending one night overnight there, just camped outside the MSF tents that they had put up. Then our team lead, Kevin [M.] De Cock was our team lead again. He flew in with the World Food Programme because again, there were food needs. What are the needs these communities have that'll help keep people ensured that they're safe, that they are cooperative, and partners in controlling the outbreak in their community? He came to assess the situation on the ground, see for himself what it's like to be in one of these remote locations. I remember one of my colleagues, who is--flew in with Kevin, and she 00:41:00[Kristin Keoman] replaced me. Jose stayed and Romel and I left with Kevin. As the helicopter was taking off, you saw how remote this place was. It was just a few hundred structures, small, little structures, huts, and small buildings where people lived. As you got further and further from the ground, it was like a circle cut out in this huge jungle. Then you'd see these small little pathways connecting to even smaller spokes where even smaller, like, sub-villages were located. This was in the middle of a huge--it was just trees everywhere. To get 00:42:00to these places, it was either hours of driving through these terrible roads, where they would sell gas in glass jars on--occasionally, you'd drive through a small, little break in the forest, and there'd be a crossroads where somebody's selling gas in glass jars. Or it was a helicopter ride. It took us hours to drive up there and forty-five minutes to fly back to Monrovia. It really highlighted the fact that there's really not easy ways to get to these places. These rural outbreaks, many people would die before people would hear about it and be able to get out there and do something. Several of the other rural 00:43:00outbreaks that I went to, it was the same thing. Flying in or flying out, or walking through the jungle for four hours with all your supplies on your back. That was in Geleyansiesu, I was going back into--that was in Gbarpolu County, and we were going back after an initial CDC team had identified a large outbreak there with many people that had died. They had flown out, identified clinical needs, a clinical team had gone in. That team had gotten chased out of that community because of the--I think that was the sequence of events. Then we were going, and because the community was so upset with all the deaths and why this 00:44:00was happening, and they [the first clinical team] left, we were the fir--but then there was a sense from the community, they needed help, so they wrote this letter asking for partners to come back in. We were the team that was--we're going back into this community. I remember, we started on Thanksgiving of 2014, and driving to--first we went to Bopolu, which was the county seat. That was on Thanksgiving, and everyone else was at the embassy for Thanksgiving. I remember ordering a burger and fries at the hotel, just figuring get as many calories in me and then just go. We went up to Bopolu, met with the county health officer 00:45:00and several of the partners, this planning meeting. What are the needs of the community, who's going? If we find individuals that might have Ebola, what are we going to do, how are we going to get them out? This process was starting to become a little bit more routinized, where there was a spreadsheet. Have we gone through their clinical needs there, infection control needs there? What are the food and other resources that might be needed? Are we thinking of providing care on site, or remotely if people can--you know, if they can walk out, that would be the preferable option before they get too ill, and where would they go? 00:46:00Making sure that there was an ambulance that might be able to meet them at one of the large riverbanks as you're walking out of the village. This is just planning that out, and then the next day we packed up, and there was a caravan of us from the health department from a couple of the partner organizations. Myself, and one of my colleagues, Laura--what was Laura's last name? [note: Broyles] Can't believe I'm forgetting it. Laura and I were the ones from CDC that were going to go when John [C.] Neatherlin was our team--he was the deputy 00:47:00on the team, and he basically was going to go back to Monrovia. He's like, "We'll plan on having a helicopter pick you up from the location in a couple of days." I had a sat [satellite] phone with me, and I charged it and I tried to find coordinates to send back to John with where the helicopter could arrive to pick us up. Then we walked for--like I said, this was the four hours, with whatever you needed to last several days out in the bush. Tents and spare clothes and food and our notebook, [laughs] and a pen, and the sat phone. We just kept going. It was amazing. The thing that struck me is I don't think I 00:48:00heard much--you're walking through the middle of this jungle, and there was no--I didn't hear any wildlife. I don't know if that's--it didn't strike me as there was a lot of animal--there wasn't a lot of wildlife in the Liberian jungle. I don't know if that's true or not, but it struck me as it's really quiet and these trees are huge. [laughs]

We kept going, and eventually, as my legs were about to give out, we finally came out to this clearing. We were met by the villagers. It was the same dynamic of, they've had lots of deaths. They're ready to accept help, and they have needs, and we had this long meeting in the palaver meeting place. We spent 00:49:00several days camped out there, going house to house, enumerating how many people live here. Are there any people with symptoms? There were some people that had been previously identified as potentially infectious, and they hadn't left, and checking back up on them. It was impressive. One of these gentlemen who ended up being confirmed as Ebola [positive] and who hadn't left, he was just sitting on his front porch area with his whole family, and we're counting backwards. He's still within twenty-one days, and it's like, what are we doing with these other people? We didn't know, and so just as a precautionary measure, having some people--maybe he should not be around some people for a couple of extra days, or 00:50:00we need to monitor--I think that's what it was, we need to monitor these additional people for X number more days from the date that his symptoms resolved from. Just trying to come up with solutions that worked there on the ground, because we were hours away from anywhere else.

One of the people that lived in the village basically said--and this probably speaks to one of the reasons maybe the Ebola outbreak got so huge--is like, there's no real healthcare facility that's anywhere near their community. It's, like, hours. Like, seven hours away walking to get to a healthcare facility. So the individuals in these communities developed a very self-reliant, self-sufficient kind of approach. We spent several days going around, 00:51:00enumerating the homes, finding out the number of people that were there, that had symptoms, setting up a system where there would be a community health worker that, as people were coming into the village, making sure that they did a symptom check on individuals. So that if there were people that they didn't know coming in--because there was this concern that there was transmission coming from outside--people coming from outside the village introducing, it's like, screening people. If there's someone you don't know, making sure that they're not symptomatic. If they are, making sure that you're contacting a health official somehow to get them to make sure that they don't start a new chain of transmission. Spending a lot of time just talking to people and explaining how Ebola is transmitted. Then also seeing the effects of what this did to--you 00:52:00know, you see children with their mother who their father had died, and vice versa. Seeing a father with his two children whose mother had died of Ebola. It was very sad, seeing this. So many people that live in very close proximity, and there's been a lot of death.

Q: Do you remember some individuals who stand out to you?

PILLAI: I do. [laughs] I can still--I can see their faces, you know. And just--yeah. It just was--it's a kind of--yeah. Yeah.

Q: Would you rather not?

PILLAI: Yeah, we can--it was--it was a lot of people that--yeah, it was an 00:53:00interesting, very emotionally difficult, challenging situation. But it was remarkable how resilient these communities were. Very somber, but they dealt with it, and they just kept moving forward. At this point, they rallied around the idea of, we have to monitor individuals and this is how we can keep 00:54:00ourselves safe. There were these partner organizations that had been funded by USAID that were going to go out to some of the more--the farmland, where some of the villagers would spend a fair bit of time. They were going to go out and actively look for symptomatic people. These processes, they were starting to take hold, trying to find additional cases.

Q: Right. So you would say you were received pretty well?

PILLAI: Yeah, in those two senses. Another rural outbreak in--where was this? This was in Grand Bassa. One of the more rural villages. Again, this idea of 00:55:00smaller villages that were further out of the--two of us had gone out to one of these smaller villages because we had heard that there may be an individual that had been to a funeral of someone that died in the larger village, and could have become a--that was a high-risk contact. So going out to find out. We were set up at an MSF camp, our tents were pitched in their complex. Where they were set up. We had spent like two hours walking through the bush, and we got to this one village. And they just did not want us there--they thought we were bringing Ebola to them. We had a guide who was from one of the villages, and no matter 00:56:00what was said, that just was not resonating. Eventually, there was a lot of--we were ready to leave--Laura Broyles. That's the name. Sorry. [laughs]

Q: No, that's good.

PILLAI: This village, it was Kristin Yeoman and I. Kristin was the colleague that relieved me in Rivercess, and Kristin and I are in the same EIS class. She and I were the ones that went out to this village in Grand Bassa. Both of us looked at each other as the voices were escalating, and we're like, we're leaving. We got up, and we told our guide, "Morris, we're leaving." We started 00:57:00heading out, and you could tell the people behind us were starting to pick up their pace. They were young men who had come in from the farms. What had happened was we'd got there, we'd asked if we could speak to people, a young kid called people in to the meeting place. That's when things started getting more--just, I guess, animated. As we started walking out, I remember, I was veering towards the left because there was a path, and I thought that's the way we came. And there was actually this older man who was in front of us, and he was from that village, and he actually steered us down the right way. Because we would have ended up getting completely lost in the jungle. He knew that this was bad and we needed to leave, and he guided us out the right way, which I was really grateful for. We started picking up the pace, faster and faster. 00:58:00Eventually we were in a flat-out run. Some of the villagers came around, some passed. At one point, one of them grabbed me by the arm, and, you know, machete. I remember saying, "Let go," because I didn't know what else to say, and he let go. I think he was so angry that with his free hand, he took a swing and knocked my glasses off. I remember at that moment, he had let go, so I spun around and I took off. I tried to make a pass at the ground where I thought my glasses were. I didn't get them, and I just kept running. Kristin and I and Morris, the guide, we kept running for a while. It felt like it took us--I think it took us two hours, carefully walking over logs, over streams and boggy areas. We made it 00:59:00back in less than half that time, probably. As we started getting into some of the other villages, we heard people screaming and yelling. But eventually, that stopped. I think in retrospect, it was probably as we got into the other villages, and they're no longer--they just wanted us out. [sneezes] Excuse me. Allergies are terrible today.

Q: Oh, I'm sorry.

PILLAI: Yeah. So we got to our base camp. I remember calling it in, and it was like, this is the kind of stuff you don't want to be reporting back. [laughs] Then everyone's going to freak out, and then they're going to pull you out. Fortunately, we were able to stay another, I think, day. We were able to do 01:00:00some--I think a day or two. Maybe it was a day. And we were able to reconcile all of our line lists for the cases that were in this community. We didn't identify any additional cases from while I was there. I think subsequently, there were some in that community. I'm not 100% sure about that. I think the keys were they had a system in place for providing clinical care, identifying cases, getting people out of that--again, they had a system. If they were too ill, they could provide care there. If they were well enough, they could get them out. Our work was done. We had went and done some active case finding, and 01:01:00then we flew out by helicopter. One of the things that that community really needed was food. It was WFP [World Food Programme] that had come to pick us up. I remember in discussion with them, the MSF people. Had a discussion with the World Food Programme, the pilots. And we reiterated it. Apparently, after they--we got back to Monrovia, WFP, the pilots, spoke with their other colleagues at WFP and ensured that food was brought back to the community. The idea is making sure that you can help the population in the affected community 01:02:00with control efforts. One way to do that is to make sure that their resource needs are being met. It was just like, you're leaving, and you see this village cut out in the middle of this huge green jungle. My six weeks were basically in those types of situations or in Monrovia, at the health department, talking to partners about, these are the things that we're seeing in these outbreaks, and these are the types of resources that might be needed, and how Monrovia-based partners could potentially support the folks that are working in these rural outbreaks. That was basically all of November and December deployment.

Q: Got you. Couple of follow-up questions. Did you do a lot of coordination with World Food Programme?

PILLAI: That was one instance. I remember some of these Monrovia-based meetings 01:03:00where that was a--I kept bringing up, we need support for--food keeps coming up as a major topic that these communities are saying. If you want to sustain this area, and people are either stigmatized when they go to the markets, or they--they need this kind of food support. I remember having that conversation multiple times within our teams and with WFP, when we would meet at the--most of the time, at their emergency operations center, where the Ministry had set up a temporary emergency operations center. So those are my interactions with WFP.

Q: Got you. One thing I just want to point out. You've just been chased out of this village, and you have to report back. It's the kind of thing that you said 01:04:00you don't want to report back because then you might be pulled out. You've just been chased out of a village, [laughs] but you really have a desire to stay, still.

PILLAI: Yeah, yeah. I think both Kristin and I, you can ask her, but it was--I remember thinking, as we were running, this is ridiculous. This is absolutely--like, it wasn't like--there was part of me that was scared, but part of me was like, how ridiculous a situation is this? It was almost laughably ridiculous [laughs] and it got just even more ridiculous, because we got to the camp, and Morris wanted to go back because they had stolen his notebook or some--or his backpack. And I'm like, we're not going back. [laughs] So I was, I 01:05:00guess by virtue of having been there once before, I was the lead. I was, like, well, we're not going. We're staying put until we get instructions. I remember calling in to Kim [Kimberly A.] Lindblade, who was our lead for the county health teams in Monrovia. Spoke to Kim, and I told her exactly what happened. She said, "I'm going to have to report this up." I'm like, "We're okay now, let us know what we need to do." They didn't pull us out, and we stayed, and we got a little bit more work done. We didn't go out into any of the adjacent villages again. I think that was the restriction. Then they flew us out. I think it was 01:06:00the next day or the day after. I think we got chased out on a Monday, and then we might have left on a Wednesday. I can't remember. But we were there for another day or two, and then we left.

It was just like things were in hand. There was a process by which to identify cases. One of the things I think in all of these locations, like in Rivercess, I remember Jose had worked with one of the people that lived in the village. Okay, if you report a case, if you identify someone that has symptoms and you're concerned about it, you want to report it to the county health--because the idea is you're not going to have someone there all the time, but you need to have a monitor that can help report. In Rivercess, they were still doing active case 01:07:00finding, and they were doing contact tracing for some of the individuals. The family that had been quarantined in that one home, if anyone had been in contact with them, they needed to be followed for twenty-one days. So Jose had set up a system where there was one or two places in the village where you did have cell phone reception. He was able to set up this system where this one person who is interested and wanted to do this would follow up on people, make sure that they were asymptomatic, and report out. Like "Today, there's no one with symptoms, there's no new cases." He set up this system where there was reporting in the very rural areas. He ended up writing it up as an MMWR [Morbidity and Mortality Weekly Report]. Similarly, in Geleyansiesu, Laura and I had done the same thing, 01:08:00where there was community health workers who were keen on making sure that their families stayed well. We told them the signs and symptoms, tried to keep it--what signs to look for, symptoms to look for, and if people are coming into the village, what to ask them for, and make sure that they contacted their county health provider or one of these partners that were going to be doing active surveillance in and around the community. In Grand Bassa, similarly, there was a pretty active presence by MSF. The county health team actually had a--I think it was someone from the county health team that had come up, or a district health worker. They had a system in place to continue to monitor individuals coming in and out of the village.

I think the whole idea of RITE, it was just: identify the needs, make sure that 01:09:00there's a system in which people can potentially report new cases, and then what to do with those individuals that are not too sick but you're concerned about. Is there a way to get individuals out to a larger Ebola treatment unit? Or if they're too sick, is there a way to give them treatment in that location? MSF had set up in both that location in Grand Bassa, as well as in Rivercess, and another partner organization set something up in the Gbarpolu location after we had left. That system worked. It really goes so much further and beyond just the idea, we're going there to set up a database. [laughter] Some of it, it may seem 01:10:00mundane. People need food. People need a water pump. It seems like really mundane stuff, but that is as important--that is probably more important to an individual than some other kind of esoteric, like, we need you to stay. Well, what can you do to help me stay?

I found that to be a really meaningful deployment. That was my second deployment. The third deployment was, I was back in--let's see--yeah, by the time I went back in May/June, the outbreak was over for two weeks. They had been declared Ebola-free by WHO. But our team was still in this response posture. We had staff that were in these county health offices, and it was hard because they're like, there haven't been Ebola cases in weeks and weeks and weeks. What 01:11:00are we doing out here? The mantra had been, for months, getting to zero. Once I got there, it became maintaining zero. I'm like, this is probably not a sustainable goal. Even before then, CDC staff like Athalia [S.] Christie had published an MMWR about probable sexual transmission of Ebola. There are thousands of survivors, so there's the possibility of a new cluster related to sexual transmission. I think in other parts of the world, Ebola is in the animal--like, there's animal reservoirs, so there could be reintroduction. This idea of maintaining zero, I didn't know if that was necessarily the best 01:12:00message. The goal in the fall deployment, it's like, find the cases, triage them, and get them care as quickly as possible. Triage, isolate, treat. That's the best way to get on top of an outbreak, and that should be the mantra. I remember going back there with Scott [Anthony S.] Laney, and Scott had been there probably twice or three times as long as I had. Scott had, I think, if you asked him, the same kind of take. This is not the way that the team should be set up at this point. It's a different point in the outbreak. It's a different point at the outbreak from our perspective, and we had a different--because we had a longitudinal perspective of seeing things on the upswing, and seeing things on a different trajectory. But I think there's some hesitance and concern 01:13:00on the part of CDC Atlanta. But they're not there. So it's like, again, you're at the leading edge of it, and you're seeing things, you should make your best judgment based on what you're seeing at the time. Then it was compounded by the fact there was still ongoing transmission in Guinea and Sierra Leone. There's these concerns, what happens if there's transmission introduced from Guinea and Sierra Leone? But you're there, and you're looking at these maps, at the IM updates. The counties that are adjacent are the--pardon me, the districts and prefectures that were adjacent to the border counties of Liberia hadn't had cases for weeks and weeks and weeks, maybe months. It's not useful to have our staff--it's dangerous actually to have our staff just sitting in these counties. It would be more productive to have them come up with plans for when there is a new introduction, how are we going to respond to it? Are we ready to respond to 01:14:00it? What would be the plan for doing that? How are we looking for sexual transmission? There was this plan for this semen testing program that had been discussed for quite some time but had hit hiccups and road bumps throughout. We were able to reorganize the staff, pull people from a lot of the border counties, and just say, I think the focus should be on basically recovery. Thinking about not the acute response, but if there is reintroduction, what are the survivor needs?

During that month, we slowly--we did pivot. The teams worked on protocols for how they might respond to a new case and share this information with WHO and 01:15:00with the ministry. And the ministry--they were all supportive of it. Spent a lot of time working on their Global Health Security Agenda. Because again, they were starting to pivot. The other countries were not as far along, but Liberia was further along. And then working on the semen testing program. That was a huge, huge lift, to create a program from scratch. Mary [J.W.] Choi was this dynamo. I remember she needed staff, and some of the reorganization helps ensure that she had staff to help with that. There was potential roadblocks, administrative roadblocks. I remember we had this meeting at the Ministry of Health where I was 01:16:00with the acting minister [Bernice Dahn] and one of her principal deputies. They're saying that this program is stuck and we needed to move forward. Within a couple hours of that, it was basically like, okay, we'll get you the letter. Within a couple hours, there was a letter that was signed. I remember emailing or calling Mary and saying, "Your letter's ready." Like, there was the official letter that says the Ministry of Health is now approving a semen testing program for all male survivors. And it was just like, she did all the heavy lift of creating how the program would operate and where they would work. She was so grateful because this roadblock of, you know, they need permission. They needed the approval, the stamp of approval of the ministry. It was just setting up a 01:17:00meeting and saying this is important to us, think it should be important to you. The letter was signed and it was done.

And then, doing some other stuff on the back end, like WHO. They were willing to support the transport of specimens because there wasn't--I'm trying to remember what the circumstances were. There wasn't enough laboratory capacity in the lab outside Monrovia, so the samples were going to be tested in the Tapita lab, which was in the northeast part of the country. They were willing to pay for the transport up there. More than anything else, it was just talking to the partners and getting people to come to consensus, agree. It was really rewarding. We got a lot done, and that semen testing program has--it's still going. None of this 01:18:00happened--like I said, Mary did the lion's share, and then Athalia came in as the next acting country director. I left on June 22nd, and within a week or two, there was a new cluster of Ebola in Liberia. Athalia was managing a new outbreak. But some of this work continued. The semen testing program became operational, and they were actually doing some of the semen testing for the new outbreak, I think both in the national lab and in the lab in Tapita. So nobody did any of this work in a vacuum or by themselves. We may have helped here and we may have helped there. There's this credibility or kind of rapport you develop with the staff there. It's like, you're seeing people again. Having a 01:19:00meeting with the incident manager is like, yes, we have been through it. The incident manager lived it the whole time. I was there in the summer, I was there again in the fall, in the winter, coming back. When you're saying something, there's a certain element of, well, this isn't someone that's just blowing in and blowing out and never coming back. So I felt like we had a good rapport with, like, Minister Nyenswah, Tolbert [G.] Nyenswah, and Thomas [K.] Nagbe in the disease prevention and control program. And seeing people like Minister Dahn, who was the acting minister when I was there in May, who was the deputy minister when I was there in July/August. It was like, familiar faces. And in just the most random ways, too. The airport manager. He would see me--like, 01:20:00he--I was there during one of the air evacuations for someone that was being flown out to their home country. This was in the summer. The embassy wanted to make sure that the infection control activities were correct. This country's air force had come in, and they were--they were there, and our colleagues from Global Migration, Tai-Ho Chen and Thomas George, were there. I remember driving there in the middle of the night. We're watching this and just seeing how they're doing things. More than anything else, a second set of eyes, being able to report back to the ambassador. Because I think there was a concern that if 01:21:00they don't do it correctly, and then there's transmission of Ebola to the crew, and then out to other people in other countries, that would be--you know, and then potentially shut down international travel in and out of the airport--that would be a disaster. So it was really important for a lot of different people for a lot of different reasons. I remember seeing the airport manager interacting with them a lot during that visit, and then seeing them again in the winter, and then again when I went back. I was just like, you just develop--you know, he's a really nice man. It's like, oh yeah, hi, again. He's your neighbor, except he lives five thousand miles away and you see him every three to four months or five months.

That was the last deployment. I remember when I was driving back out to the airport on June 22nd, it was the--what had happened was, at that point, we had 01:22:00been Ebola-free in Liberia for probably six weeks. It was right before the new case had come up after Athalia had started. And there was these rumors, lots of rumors. Oh, there's Ebola coming in from Guinea, and somebody brought Ebola in, and there was calls for shutting the borders down. There was this sense that that was not a productive--like, closing the border, there are known border crossings, but there's hundreds and hundreds of unknown border crossings. And unmanned border crossings. If someone is asymptomatic as they cross the border, but then they become symptomatic after, how is that helpful? Screening people at the border or shutting the border, I should say, is not as meaningful as being 01:23:00able to rapidly detect, triage, and respond to a case. That's the most important thing. I remember there was these calls for closing the border. It was starting to become a crescendo near the time I was leaving. There was an IMS meeting around the time I was--it was at the new IMS EOC that was across from the Ministry of Health, that I remember being very forceful. This is not--because Tolbert was looking for his partner organizations to weigh in. WHO was there, the WR [WHO representative], and UNICEF, and IMS--other IMS partners, and his EOC staff. I just remember saying, we can't lose sight of the fact that if someone wants to cross the border, there's a lot of places that they can cross 01:24:00the border that you're not going to catch them at. It's a cosmetic fix, and it's one that will give a false sense of reassurance. This idea of detect, triage, and respond to a case is the most important thing, and it won't do anything about local trans--like, sexual transmission, won't do anything about animal reservoirs. I remember saying that, and he's like, great, okay, we're good. Because he needed to present at the Senate, because he was asked to testify. And then I think our--Yolonda [V.] Freeman wrote some talking points because she's our communications person. I remember making some edits, clearing it with Barb [Barbara J.] Marston. And then he had his talking points as well. It was printed on the Liberian Ministry of Health letterhead. Then it was like, oh, yeah, this is really nice, he's going to use this. And then I don't know if it was that day 01:25:00or the next day--it was the day I was leaving. And he's like, can you come with me for, basically, support? I'm like, okay. But I knew I was cutting it close because I needed to get to the airport.

Alex [N. Gasasira] is the WR from WHO, Athalia is there now, she's there and I'm there. I just assume we're hanging out there. Then Tolbert's giving his prepared remarks. They're like, we've given special dispensation to the WR from WHO, and the CDC representative made comments, and so then I was like, okay. Then it's like, trying to think. I must have known that we might be asked to speak because I remember checking with the embassy, is it okay? They're like, that's fine, we don't think you should close the borders either. It was interesting. It's like, 01:26:00they--advocating for--or just providing a public health rationale for why you wouldn't do that. It was interesting. I said my piece, basically what I'd said at the IMS meeting. Basically restating what Tolbert said. Then my work was done. I turned the baton over to Athalia, and then I drove off to the airport. They didn't close the borders, and I was like, okay, that was the right decision. And within a week, there was a new case, and it wasn't at a border. It was not linked to someone coming in from--and they rapidly--they detected it, and then they rapidly started kicking off response activities and partners got pulled in. Scott Laney and David Blackley, Athalia Christie, Chris [Christopher] 01:27:00Gregory, they were there from the CDC side. You saw these guys go into response mode, and with the partners. It was so different than a year prior. It was an amazing thing to see. It was this idea of just, Liberia was so far ahead compared to the other countries. They had eradicated it, or they had controlled the outbreak, they were Ebola-free. They had a new cluster, I think they were Ebola-free again, and then had another cluster. I think that happened two or three times before the other two countries had done it once. They got good at responding. CDC played a part in that, and not a small part. These people that 01:28:00I've talked about over the course--they did it. They did the work, and they were the--they worked hand-in-hand with the ministry and WHO and UNICEF and all these NGO [nongovernmental organization] partners. They were a big, big, big part of why this response ended the way it did. At least in Liberia. I think we--CDC contributed--they did a good job. They rose up to the challenge. It was hard. And these people that I worked with were just amazing. So--

Q: I want to make sure that I'm not making you late for whatever your next thing is.

PILLAI: Oh, I better check.

Q: Yep. Sorry.

PILLAI: Let's see. Yeah, I'm sorry my allergies are so bad.

Q: No, no. I'm sorry. I wish that in this closed space you didn't have--you could have a break from it. But--


PILLAI: Yeah, I just need to--I got another probably ten minutes or so.

Q: Okay. Great. Well, I was hoping that we'd--okay, one diversion it sounds like. When I have asked people about the ring countries, which I take to mean the countries that are surrounding the three worst-hit countries in West Africa, people have recommended that I speak to you about Senegal. Were you involved at all with Senegal?

PILLAI: Senegal? Me? No. No.

Q: No? Okay. [laughs] Got you. Probably just somebody who thought of the wrong person.

PILLAI: Yeah. Who--you can talk to Kinzer. Have you talked to Mike [Michael H.] Kinzer?

Q: Yeah. I haven't yet.

PILLAI: Yeah. He's the country director out there.

Q: Oh, is he? That would be great, that'd be perfect. Okay. So, then I just want to talk about shutting things down. Being the last incident manager.

PILLAI: We shut the response down in the midst of ongoing--there was 01:29:00transmission that was occurring from Guinea all the way down to--like this remote village in Guinea all the way down to Monrovia. And we shut it down even in the midst of that. Two countries, remote transmission, transmission in an urban setting. Those were all the things that we were talking about as--you know, those were the things that we were really scared about and concerned about for two years. But by that point, we--the partners, the country, they were doing their job. They were able to rise to the challenge. We didn't need the EOC. Was there an Ebola response? Yes, there was still a need to respond. There was 01:30:00infection control things that needed to happen. There needed to be appropriate laboratory testing. But the folks in-country, the country offices and the WHO people, the partners that were there, the Ministry of Health colleagues, they knew the drill and they quickly fell in place. Was it flawless? No, but nothing is flawless. Every response can be messy. The work got done, and it got done in as orderly a fashion as you can imagine when you're dealing with a public health emergency. These are talking about--you know, it's people, and biological agent, and transmission, and folks that can be asymptomatic. And then become 01:31:00symptomatic and transmit to other people. It's not clean. Recognizing that you need to be--you have to have confidence in the systems that you spent two years helping develop, confidence in the partners that you've spent all this time working with, and that they can do the work. And just believe that the system will work, and it did. We in Atlanta were, like, do you need more help? At times, the response was no, we got it under control. The staff on the ground--we didn't send a huge number of people to Liberia, or Guinea, for that matter. It 01:32:00was just this orderly--what can we--do we need this function? Do we need this team to be reporting on a daily basis or a weekly--and as each of the tasks became more routine, and could be handled by their home program, we just let it transition. March 31st, it was just like, we're done. It was a remarkable--I think the way we closed it out was interesting. It wasn't like a zero-case--it's very different than when we started. You would think we've stopped transmission, there's no more disease, and the response ends. This is actually--there's ongoing clusters, but we have them under control, and the systems are in place. 01:33:00The EOC and the incident management system exist for coordination and a venue for people to come together. We didn't need that venue anymore. The systems were there.

Q: Were there some people who were anxious about shutting down, both inside and outside CDC?

PILLAI: Initially, I think the plans were to end the response by March 1st. What happened is they had gone from a level one activation, which is the highest-level activation, resources from all over the agency should be available, to a level two by mid-February. The idea was to end it on March 1st, two weeks later. And it was felt that there was too many staff still on the ground, and if this had been any other circumstance, you wouldn't be shutting a 01:34:00response down with this many staff deployed. And like, okay, it's--[sneezes]

Q: Bless you.

PILLAI: Excuse me. So we had six additional weeks. We extended it to March 31st. And we would do a periodic pulse check. Do we feel comfortable? [sneezes] Are there concerns that people have, you know, as we stop certainly--for example, clearance stopped for most activities through the EOC and started going to home programs. And we gave different functions back to the home programs. And people an opportunity to say, are you noticing a problem? Are there any things that are falling through the cracks that we need to address? Over those six weeks, we were able to do an internal pulse check. By the time the new cluster arose, 01:35:00which is I think around mid-March, the question is, do we feel comfortable with this? What would make us feel uncomfortable? It's like, well, if there's increasing resource demands that the in-country staff can't handle. We had developed a kind of a checklist of, like, what would be the criteria to potentially reactivate the EOC? That was one of the demobilization steps. The need to coordinate across multiple centers; resource requirements in-country that exceeded capacity of in-country and host country resources; transmission in countries outside of the highly affected Ebola countries that didn't have the resources. Things to that effect. Once the transmission occurred in Guinea and in Liberia, looking at the list, we felt like no, things seem to be in hand. And 01:36:00then we could always reactivate if we needed to, but we felt that we were able to end it. And we did. And yeah, it's been--what is it, six months now about?

Q: Yeah.

PILLAI: So I think it was an okay decision. [laughs]

Q: Yeah. No doubt. So is there anything that we haven't talked about so far that when you look back you want to add to the historical record?

PILLAI: I guess the only other thing I would say, it's not like--I spent probably more time in the EOC than I did in Liberia. The time in Liberia was probably personally more meaningful and rewarding because I was there. The one thing that I think having gone back and forth, and then having the opportunity 01:37:00to be in the EOC and be the Liberia technical officer, and then go back, it was helpful because I was able to articulate Atlanta's perspective when I went back. And when I was there, I was able to articulate what the CDC Liberia perspective was and understand where Atlanta might be coming from when they were asking for certain things, but then be able to push back when I thought, no, that's not what needs to happen. Because I know where they're coming from, I knew what the situation on the ground was, I knew what the situation on the ground was a year prior. Just having that longitudinal experience was really important, having the experience on both sides was really helpful. All of that lumped together was 01:38:00really helpful for the last two months or however many months--yeah, two months when I was on the response in an acting IM role. Just knowing where people--like, it's always best to defer to the people on the ground for the operational and tactical decision making, and the goal as you are further away from where the action is, just thinking about what the strategic issues are and how you can support the people on the ground. I hope I did that. When I was in Atlanta, that was the most--it was most rewarding when I was actually helping the country directors, acting country directors, that followed me. Like when Athalia came in or Paul [J.] Weidle came in, being able to say, okay, yeah, this is what I had done and this is what I'm hearing here. You feel like you still 01:39:00had that connection through them. And these are folks that you know, and having the same folks in the pool going back and forth to the outbreak site and coming back to the EOC. These are people that I feel like I have developed a lot of rapport and a strong relationship with. So I guess that's it.

Q: Okay.

PILLAI: Thank you very much.

Q: No, thank you so much. This has been great.

PILLAI: Take care.

Q: Yeah. You too. You've given me a lot of time, and that's a real gift.

PILLAI: Oh yeah. I appreciate it. It's good to kind of get it off my--off my chest.

Q: Good, good.