Dr. Satish Pillai

Dr. Satish K. Pillai

Q: This is Sam Robson here today with Dr. Satish Pillai. Today's date is August 16th, 2016, and we're here in the audio recording studio at CDC's [Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Dr. Pillai as part of the CDC Ebola Response Oral History Project that our David J. Sencer CDC Museum is doing. Dr. Pillai, thank you so much for being here with me. For the record, could you please state your full name and your current position with CDC?

PILLAI: Satish Krishna Pillai and I am the deputy director for the Division of Preparedness and Emerging Infections in the National Center for Emerging and Zoonotic Infectious Diseases.

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

PILLAI: Cleveland, Ohio, and August 13th, 1972.

Q: Did you grow up in Ohio?

PILLAI: Yeah, I lived there almost until the age of twenty-eight and then I moved to Boston to continue my training. So I went to school in the Cleveland 00:01:00area. I was an undergrad at Case Western Reserve [University], which is in Cleveland; medical school there. I did my residency in internal medicine at the University Hospitals [Case Medical Center] and then I moved to the Boston area to continue my training in infectious diseases. I was at the Beth Israel Deaconess [Medical Center] and I was there from 2000 to 2006. I worked on clinical work for the first several years. I did research in antimicrobial resistance and then I thought I was going to go into more of a clinical kind of career in infectious diseases, but by 2009 I felt like I was looking for a 00:02:00broader potential impact on public health. I started work towards my MPH [Master of Public Health] at the Harvard [T.H. Chan] School of Public Health.

Q: I think that's going to be a great position for us to pick back up. If it's okay, I kind of want to back up just a little bit.

PILLAI: Sure thing.

Q: Can you describe the household in which you were raised?

PILLAI: Immigrant parents, first generation, me and my younger sister.

Q: What did your parents do?

PILLAI: My dad was a radiation physicist and my mom for the first several years was a house mom and then she went to work and had a variety of different jobs, mostly as an administrative assistant, executive assistant.

Q: What kinds of things did you like to do when you were growing up?

PILLAI: Watched a lot of TV [laughs], just a lot of outdoor activities with kids around the neighborhood. I ran track in middle school. I played tennis in high school and just kind of run-of-the-mill American kid.

Q: Did you know that you were interested in medicine back then?

PILLAI: The idea of medicine, I don't know if I knew exactly what that meant, but it was something that I aspired to go into. But I didn't know what exactly a physician's job day-to-day would be like.

Q: So when you off to college, Case Western, what did you think you were going to be doing?

PILLAI: At college or beyond?

Q: At college.

PILLAI: I kind of locked in on a biology major and I was a biology major, 00:04:00chemistry minor--again, figuring that I was interested in medicine, so this would be a good kind of path towards getting all my requirements and kind of getting me in good stead for what I anticipated the classwork would be like in medical school. I finished college in two and a half years and then I had, as a high school student again, like I had this vision of wanting to go into medical school, so I was actually accepted into Case's. They had this combined undergrad medical program, so I finished school early. I ended up starting medical school one year earlier than I would have otherwise, and then I started medical school.

Q: Gotcha. Wow, you started medical school at twenty, twenty-one, something like that?

PILLAI: I was probably a couple weeks shy of my twenty-first birthday.

Q: What was medical school like?

PILLAI: The first couple years are a lot of classroom activity. It was interesting, but again, it didn't really give me the full sense as to what I would actually be doing, but by the time I was on the wards as a third-year medical student, that was like the beginning of my experience of what clinical medicine would be like and it was amazing. It was like you were daily interacting with so many different people--the patients, your colleagues, your fellow students, the staff that were teaching you, the residents, the nursing staff and all of the different people in the hospital environment. It's very vibrant, very interactive, and you felt like you were doing something, you were 00:06:00moving things forward every day. Very early on I remember it was kind of like--again, this is like August of '95. I remember you learn something as a--it was in my internal medicine rotation and there was the clerkship director. In your third year you have different clerkships and medicine is one, surgery is another, pediatrics is another and so you spend like several months on each of these blocks. It was my first large clerkship block and I remember very early on the clerkship director was, "You stay here"--and this is before eighty [hour] work week rules. "You stay here until the work gets done. You don't leave. This actually impacts individuals' lives." It was a very eye-opening kind of 00:07:00experience. It was like yeah, there's actual implications, impacts on people, and so you don't leave the job half done. You see it through and again, that's probably not how training is now and even residency it's different. There's shift work. But I found that to be a very profound statement and it's been something that I've carried with me for quite some time now.

Q: I'm really glad that you shared that.

PILLAI: Twenty-one years probably [laughter], hard to believe.

Q: Well I know that we're going to see that when we get to Ebola. So what happens after the medical school?

PILLAI: So then I join the same place, the University Hospital, I was an 00:08:00internal medicine resident. And again, before eighty-hour work week rules, it was very intense, very exciting, just learning by just doing. There was so much experiential learning working with people that were your seniors, like you're an intern, there's residents above you. There's chief residents and attending physicians and just so many different work environments and I naturally gravitated, probably because of peers and role models--there was a lot of very dynamic people in the infectious disease division and so I spent a lot of time doing those types of rotations.

Q: Do you remember anyone specifically?

PILLAI: There's Keith [B.] Armitage, who was the program director for the residency program, and he was just a very dynamic person that was very engaging 00:09:00and he was also an infectious disease physician. There was others like Robert [A.] Salata. He was at the time the division director in infectious diseases and he was a very--his fund of knowledge was amazing. The different specialties in internal medicine, you spent a lot of facetime with the nonprocedural specialties, like cardiologists may go off and do their procedures, catheterizations and whatnot and gastroenterologists the same thing with endoscopy, but the practice of infectious diseases is basically examining people, talking to people, talking amongst your peers and colleagues and discussing the case, reviewing the laboratory. So there is a lot of back and forth and thinking through things and thinking about what all could be going on 00:10:00and then trying to narrow down based on experience and your fund of knowledge, well, what is the best path forward? So I spent a lot of time doing those types of rotations on electives, and then I spent a lot of time in the intensive care unit as well because I really enjoyed spending time in that environment of just decisions need to be made. There are very critically ill people that need care and you just have to get the work done. Those were the two areas that I enjoyed the most.

For a long time I thought maybe I could do both. There are some people that are infectious disease critical care physicians, but I ended up going to a program after residency that was very research focused. So I spent the first couple 00:11:00years doing clinical infectious diseases for my training purposes in Boston and then I went into a laboratory environment. Actually, in retrospect it was a good experience because I learned that that didn't suit--clearly, it was not the dynamic environment with like a lot of interaction with people, at least in the work I was doing. I found that to be not a good fit. Still trying to figure out what I wanted to do. After that I went into a more clinical position; a lot of work, very exciting. I learned more probably infectious diseases in that short time than I had in all of my prior training just because there were so many 00:12:00patients, a lot of volume, a lot of complex cases. But again, there was something--I felt like I wanted to do something a little different. I couldn't quite figure out what that was.

My sister was an EIS [Epidemic Intelligence Service] officer, but she's my younger sister. She had done a similar path. She went to medical school, she was a pediatrician. After pediatrics, she did an infectious disease pediatric fellowship. Then she got her MPH and got a preventive medicine degree, and then she applied to EIS and was accepted. At this point, she's like, you should consider this. You're looking for something more--something more broadly impactful. I'm not even sure if that's a word.

Q: I always use it.

PILLAI: But I was like no. I'm in my mid-thirties now. I'm kind of set here. She's like no, there's older people that apply, and so I was like well, let me think about it. I'm not even sure what this means. I think by now it's 2009 and I applied for the School of Public Health at the Harvard School of Public Health. I got in, I started doing coursework. At first I thought well, I don't want to make any huge changes in my life. Maybe I can do hospital infection control that has some epidemiology, it's clinically focused and it's an infectious disease background and I stay in a hospital environment. But the more I took the coursework and the more time I spent in my clinical career, I was like yeah, you know, I think there's so much more that's beyond simply--I think 00:14:00even in my EIS application, I might have said something about, like, my career to date has been within the confines of the four walls of a hospital and by the time patients got within that, so many of the reasons for why they ended up in that position had been predetermined. There are so many social determinants and predisposing factors that may have prevented them from being at the ICU [intensive care unit] in septic shock or having a diabetic foot infection that now needed surgical management. I spent a lot of time in my clinical career in the ICU and managing complicated infections. Maybe there's some other things I can do to either address these issues on a more population level, prevent them 00:15:00on a population level.

I think at that point I was like, I'm not sure if infection control is really where I want to be. By 2010 I guess it is, I was halfway done with my MPH because I was working and doing my coursework at the same time. I applied for the EIS program and I was fortunate I got in and then I started in the summer of 2011, I came down to Atlanta. I made a conscious decision during the match week when all the applicants come down to see all the different programs, I was going to actually consciously try to not match to an infectious disease program so I can get some different experiences. Fortunately I matched in a position at the 00:16:00National Center for Environmental Health. That was their health studies branch, and what was the draw for me was they billed themselves as kind of like they did field investigations. Again, the idea of being outside the confines of a hospital environment. They were flexible and I had a great primary supervisor. He was somebody from the outset--said like if there are opportunities that are outside the center he would advocate for them. I didn't see any downsides in the position. I'd get to do something outside infectious diseases, get some field experience. If there were opportunities outside of NCEH I would get an opportunity, and sure enough, that's kind of like how things transpired.

Q: Who was this person?

PILLAI: Matt [Matthew W.] Murphy. He's currently I think the President's Malaria 00:17:00Initiative CDC assignee in Ethiopia. He's a really great, great guy and he--I think because of Matt's championing my opportunities, I was able to quickly--I quickly got through all my Core Activities of Learning.

There were opportunities to go to Kenya for polio. The EOC [Emergency Operations Center] was activated during my first year of EIS for the polio response, so that was my first opportunity to do something slightly outside of NCEH, but they were looking for people that had an infectious disease background and they were looking for lots of people at the time. I was like well, I've got a clinical infectious disease background. I hadn't at that time ever been to Africa before, 00:18:00so it was my first opportunity to go internationally for a public health response. This will be great. I spent three weeks with a large team in Kenya doing rapid surveillance of their acute flaccid paralysis surveillance system. They also were doing surveillance where they were trying to get as much done in one fell swoop because they had a lot of people coming in and they were trying to also do a rapid assessment of their vaccine preventable disease kind of surveillance system.

It was interesting because that was my first exposure to (1) working in Africa, (2) interactions with WHO [World Health Organization] and ministries of health and CDC and how they interacted with these different organizations. There was 00:19:00good and bad. CDC was able to kind of mobilize a large team immediately, and there's just these mechanisms that CDC has to embed people within the various teams. That was my first exposure to what a CDC country office was like. It was very interesting. The downside was I also saw what happens when you rapidly pull things together, try to put together a project on the fly and the surveillance tool and the interview tool that was being put together was put together by multiple different people that had different needs and different kind of perspectives. The questionnaire that was eventually put together that staff that 00:20:00would go out in the field that would administer had questions from the Ministry of Health, WHO, CDC, UNICEF [United Nations Children's Fund]. Different groups that all have a stake in vaccine preventable diseases, polio eradication, but everybody just kept adding and adding. I remember thinking to myself, this is an unwieldy instrument. It hadn't been really piloted because there was this urgency to get teams out in the ground, into the field. I remember we were driving off and I'm pretty sure it was like if there are edits, you can kind of maybe get them printed up when you get to the county--I think it was called counties--like the next administrative level down from the national. Province or county, I can't remember now--or in the district health offices, which would be 00:21:00the next administrative level down. When I got to Central Province, that again, this is my first exposure to working internationally and it was very clear that they didn't have the resources; like if there were edits, we would use up all the toner [laughs] and their paper, so it wasn't really practical to expect we would be printing up another dozen copies of this multi-page instrument. The questionnaire took multiple hours to administer and we were just consuming hours of time and there was this kind of elaborate process of making sure that everybody--WHO, the Ministry--all the partners had an opportunity to ask their questions. You really realize that the ideas that people have at the next 00:22:00administrative node up, whether it's at the capital or Atlanta or Geneva, have to be informed by the issues on the ground and if the questionnaire had initially been trialed in one of these locations, it might have been a much more informative exercise. There was still information that was gathered, but again, it was an eye-opening experience for me. I was like wow, you go and they're thinking well, this is WHO and CDC and the Ministry of Health and we're going to go in there and we're going to administer this tool and it's going to work out even though it does seem kind of unwieldy and bulky.

But people want to tell you what they're doing and they tell you their 00:23:00workarounds and they tell you the resources that they lack and how they come up with creative solutions and that was probably the most illuminating thing in the whole response. It's like yeah, the ideas don't have to always come from top down. They need to be informed by the needs and the workarounds that the folks that are actually doing the day-to-day work and interacting most directly with people that are impacted by whatever the issue is, whether it's--they get vaccines or not. That was a time when I realized, oh yeah, to ensure that people 00:24:00have, you know, like the maintenance of vaccine cold chain. They need these generators and these generators need fuel and if they don't then the temperature goes up and down and the vaccine quality may not be--it's like, there are a lot of things that you take for granted and there are some very concrete things that people need, whether it's fuel or minutes for their cell phone. It was eye opening. I had the opportunity to kind of work on environmental health and several epi aids and emergency investigations. The fungal meningitis outbreak, West Nile outbreak, which was my first exposure because again, they were looking 00:25:00for someone with a clinical background; a second-year EIS officer at the time, so they wanted a senior EIS officer to work with the first-year EIS officer.

I had the opportunity to go on a West Nile outbreak investigation, so it was my first foray into working on a large infectious disease outbreak and then right after that was the fungal meningitis outbreak. So then again, I got to work on that. It was because of the clinical background. All my past experience really helped with what I ended up doing during EIS. So between the field investigations going out to Navajo Nation to do water quality studies and just 00:26:00seeing how people come up with creative solutions to address challenges that they face and all the outbreak investigations and being out in the field, it gave me a good sense there's only so much you can do from working in your office. The actual work and actual needs and solutions are often found by getting out and working in the field.

Q: Did you stay on with the same group after EIS or what happened?

PILLAI: No, I made the conscious decision I was going to spend a couple years outside of infectious disease, but at this point I'm in my forties at this 00:27:00point. So I'm ID trained and I have a decade-plus experience in doing medicine and infectious diseases. That's where I should try to leverage that experience in whatever I do next, and so I ended up finding a position in emergency preparedness. It's almost like the analogy of working in the Emergency Operations Center, it was kind of like working in the ICU. I felt like that tempo might fit with my personality, and so the position I ended up getting as a CDC staff member was in the Division of Preparedness and Emerging Infections. They were looking for someone that had clinical experience that could work on clinical guidance for the issues related to preparedness planning for flu, for 00:28:00anthrax, for different types of bioterrorism agents, and also during emergency responses be available to work in the EOC. The clinical part, I was in practice during the H1N1, 2009-2010 outbreaks. I figured this would potentially be a good fit. I can help with guidance writing around those types of topics, clinical management issues, and then if there were opportunities working in the Emergency Operations Center, that would also be a good fit. That was the general parameters of the job, so I'm like sure. I'd like to try this, and it ended up being a really good fit.

Shortly after joining the position, there was an H7N9 activation of the 00:29:00Emergency Operations Center and I got to work on the medical countermeasures team in the EOC. Looking at issues of use of respirators, and I got to work with folks from the [Division of] Healthcare Quality Promotion and the NIOSH [National Institute for Occupational Safety and Health] worker safety folks and people from the influenza division and Influenza Coordination Unit. It was really robust modelers from the Health Economics and Modeling Unit thinking through clinical questions, thinking about infection control issues, worker 00:30:00safety issues, and it fit a lot of my past experiences. The response required quick turnaround times and you realize how decision-making has to occur. When you have limited information and you have to provide different options for people based on the available information and how that process unfolds. So it was a great opportunity to see how CDC does just that.

Shortly thereafter, I kind of settled into my position and continued to work on some flu-related projects and before you knew it, I was back in the EOC by I 00:31:00think the spring of 2014 during the MERS-CoV [Middle East respiratory syndrome coronavirus] activation and again, I was in the EOC.

[interruption]

Q: Dr. Pillai, you were talking about how you got involved in MERS coronavirus.

PILLAI: I got involved because during my time in the H7N9 response I guess because of the work I had done there, the deputy incident manager, she was the deputy director for the Influenza Coordination Unit and she asked my supervisor if I could help in the MERS-CoV response and he said if I was interested I could do so. So I spent about two months on the response and it was very interesting. 00:32:00What I'd learned is CDC, we're structured around specific subjects, subject-matter experts and they have knowledge about a pathogen. There will be epidemiologists that know about it. There will be laboratorians that know the diagnostics for that. But in these emergency responses, oftentimes there are many other factors that end up being involved and it was interesting to see how it's important to know the biology or the virology, but there was a lot of infection control issues because there was spread of the virus in hospital settings, so there was the need to involve hospital infections folks and [DHQP], 00:33:00worker safety issues were involved. People from global migration were deeply involved in the response, because what does it mean if someone was potentially infected and was on a plane and traveled and came to the United States? What happens with airline screening? So you start seeing wow, it's not sufficient just to be knowledgeable about the organism per se or the diagnostic testing per se. That's important because that's how you track the tempo of an outbreak, but what happens on the ground and the impact this has on people isn't just simply 00:34:00counting cases and doing testing. There is actual guidances that have to be written for healthcare workers and for clinicians that may be caring for individuals--for people that may have been exposed on an airline, and how to potentially decontaminate surfaces. Just things that you didn't think about, but those are the questions that come up. When I came to the Emergency Operations Center, I was like wow, there's a lot of people here working on a lot of different activities that you wouldn't necessarily think related to the MERS-CoV outbreak.

When I got there I was helping with some of the staffing and managing some of the teams that were going out to the Middle East, to Saudi Arabia, because 00:35:00that's where the vast preponderance of cases were, with hundreds of cases--I think it was like five hundred cases in Saudi Arabia--maybe a couple hundred in I think it was the UAE [United Arab Emirates]. Teams were going out there to do hospital investigations, community investigations, trying to understand how MERS was being spread. What were the risk factors? That's where the outbreak was focused.

The fascinating thing was during all of this there was a domestic case in Indiana and then another domestic case in Florida and I just remember by the time the Florida case occurred, there was so much media attention that it was 00:36:00really hard to manage. We were trying to get people out the door to go to where the outbreak was occurring, but there was so much concern and anxiety here and I was like wow, two cases can generate this much attention. What happened for the response is it took a lot of time and effort to address the concerns. It was great that there were these folks from all the different teams like worker safety and hospital infections, the communications people, they were all there, but it was a noticeable impact on our ability to keep focused on the teams that 00:37:00were going out the door.

I was like wow. There's more to public health emergency response than just going and doing these studies. There's also the communications component and risk messaging and getting out there quickly, promptly, providing the information that you do know and also what you don't know. That was an important lesson. If you don't manage passing information along in a timely manner, that space gets taken up by people that may not know all the details. So it can end up being 00:38:00somewhat detrimental to your overall response.

Q: I have a couple questions. Staying on topic for just a second. Did those domestic cases, did they have--and I just want to make sure I'm understanding everything right. Did you feel they affected the international response, the people going out and doing things overseas?

PILLAI: I thought it impacted our--there's a finite number of people at CDC and the way that the response was set up, it's like there's one incident manager and deputy incident manager and there was one group of people that are trying to keep their eye on both the international side and the domestic side and it just 00:39:00required people working even harder, longer because you have to address all the issues that those teams have, but also address the concerns and issues related to the domestic activities. That's what we have to address domestic health issues as well and that's our primary focus and the whole point of having teams go out there is to understand the way this infection is being transmitted to help reduce the chances of transmission here and abroad. It all kind of fits together, it was just interesting to see how much attention and focus two cases had relative to hundreds of cases and how that can be difficult to balance. 00:40:00David Swerdlow was the incident manager then and I thought he did a really admirable job because he was trying to balance all of these different activities. It was a really interesting experience to see how all of this fits together. There are so many different parts to CDC and during the emergency response they all have to work together. It's not all about just basic science. There are laboratorians, laboratory diagnostics. There's the epidemiology. 00:41:00There's the communications piece. There are all these different components that have to work together or have to share information, have to make sure that what one group is saying is consistent and informed by information that another group may have. Worker safety may need to know what the infection control people are saying. It was again, very interesting.

Q: Did you observe frictions between different groups?

PILLAI: I don't know if it's groups, maybe philosophically. CDC is an evidence-based public health agency and during an emergency response sometimes you don't have all the information--at least it seems like you don't have all the information available that you might want to have available to make a 00:42:00decision. Clinical medicine seems to have that as well. Based on your diagnostic evaluation and based on clinical judgment, you have to make a decision and execute a plan because sometimes you don't have all the information available when you have to make a clinical management decision. Similarly, it seems like when you have to make a public health decision, you may not have all the information. I think it wasn't friction. It was a very collegial, good working environment, but some people are more deliberate because they are public health practitioners. They are strong epidemiologists and laboratorians and they want 00:43:00to have as much information as possible to make the most informed decision, and the tension is sometimes you just don't have all that information and you still have to make a--because in the absence of that there is no guidance. What are you supposed to do now? That sometimes is the tension in the emergency response.

Q: And then what happens after that?

PILLAI: End of June, I had been approached. My supervisor said, "There is this 00:44:00concern that there are more cases of Ebola than they expected in West Africa. Are you interested?" So, in November of 2013, because I was working in like planning--part of my job was writing clinical guidance and planning. I was asked to be a speaker at a conference on different types of hemorrhagic fevers, so I spent a week or ten days, but basically different audiences going over all the 00:45:00different hemorrhagic fever viruses from Ebola, Marburg, yellow fever, dengue. Some I would potentially consider obscure viral hemorrhagic fevers. But it was interesting. I'm probably never going to see these, but I reviewed the materials and I was able to talk to some of the experts here and then I gave the presentations. I thought it was an interesting experience and I chalked it up to I learned something. That was in November of 2013, and by end of June, early July, my boss said, "The division director Inger [K.] Damon has been looking for 00:46:00additional people that may be able to deploy to West Africa." I was like "Well, I'd be interested. I've only been to Kenya, that's my only experience working in Africa. I think my understanding is it's far less developed in West Africa, so I don't know if I have the right skill set of interacting with the ministries of health and I'm not sure what you're looking for, but I'm happy to help out in whatever way I can."

I was like, let me know, and I didn't think much more of it. My understanding is there was all this discussion occurring in the background because at that time, they hadn't activated the EOC. I think my name got kicked around because I'd 00:47:00just rolled off another response. Then I was like, I have some guidance work that I need to work on, and so I was busily working on that, and then I got contacted by I think Inger Damon saying your boss, Toby [L.] Merlin, said you might be interested. I'm like, sure. By that time--I don't speak French. I can probably go to Liberia or Sierra Leone, but I think at that time, I don't even think we had--I think we might have had one person in Sierra Leone, or very few. They were like, we are looking for people to potentially go to Liberia. I'm like oh, okay, well, let me know. I was just trying to figure out my schedule and I remember having a conversation with Ute Stroeher, and I was like "Well Ute, when 00:48:00do you need me to go? I could go now, but it sounds like you're still trying to figure things out." She's like "Well, I think this might continue to go on, so if you wanted to go later in the fall, we probably will need help then too." I don't think anyone really had a full sense even at that time of how long it would go on for. I was like "I'll go now because I think I can carve out the time now and I don't know what November will look like." In retrospect, I'm glad I did go when I did. It was probably the single most eye-opening experience in 00:49:00my life.

Shortly after the EOC activated they started getting our paperwork together to go and it was framed very much as we're going to go there to count cases and make sure that the Ministry of Health [and Social Welfare] is putting the case report forms into the Epi Info viral hemorrhagic fever module and these are the case definitions. It was very classic kind of. You go out there. You count cases. You look at the data and there is contact tracing that occurred. You just need to make sure that they're doing contact tracing and following-up on these people for the twenty-one day period. This is how the process works. I remember getting a briefing and meeting with Ute and Barbara Knust and I was like, oh okay. At the time, they were like, you will be a team of six or seven, seven, 00:50:00and Kevin [M.] De Cock is going to be the team lead, he's coming from Kenya. I had never met him before. And there's going to be five EIS officers and I had met one of them, [M.] Allison Arwady, who had been one of the deployers to Saudi Arabia for MERS and so she was deploying. Almea [M.] Matanock, Joe [Joseph D.] Forrester, Patrick Ayscue and Jen [Jennifer C.] Hunter. Those were the people that were the EIS officers. I was neither an EIS officer, nor was I a senior CDC person, so I'm like, I'll do whatever you want me to do.

We got there and Almea, Patrick and Kevin had gotten there a couple days before us. I think they got there three or four days before and they were describing--it wasn't consistent with what we were being asked to do. They were like, we can't even figure out where the information is coming from because--what we were being told is we would count cases and we would work with the Epi Info module. They are trying to figure out where information was coming from. Was it hospitals and morgues, the two Ebola treatment units? There were only two in Liberia at the time. And call centers, and is this information accurate and how are these case reports being filled? It was very different and 00:52:00I was like, well I'm not quite sure how this all fits together, but I guess we'll figure it out when we get there.

We got there and it was clear that there was a disconnect between what we were being asked and the situation. This idea, we'll just collect all the information and put it into this electronic database, and we get there and the very first meeting we went to at the Ministry of Health, it was just chaotic. There were hundreds of people in this conference room. There was no clear agenda. They would go over these case counts that you are unclear where this information came from. There were no decisions that were being made, just ideas thrown out. You weren't even sure who all these people were. Were they NGOs? Were they Ministry 00:53:00people? Were they coming from other international--like CDC? Were they ECDC [European Centre for Disease Prevention and Control]? Were they WHO? Were they people that were family members of cases? You just didn't know who was in this room and why information was being presented in the way it was. It was very disorganized and I think it partly reflected the fact that they just didn't have a system in place for regularly meeting. I remember Kevin saying, "They need an EOC-type structure." He's like, "We should try to help them with that." One of the things that we did very early on was just try to establish some kind of 00:54:00structure. Meetings have to start on time, have an agenda. You should have select people at these meetings that are empowered to make decisions. Again, kind of modeled after what we tried to do here in the EOC.

One of the things that was noticeable was the person that was in charge was the Deputy Minister of Health, but she was also trying to deal with all the hospitals and clinical issues. There was the Ebola response, but she was also like the chief medical officer. I believe she was a chief medical officer at the time as well, so she's dealing with the routine kind of clinical issues that the 00:55:00Ministry of Health had to deal with. So she was just wearing way too many hats and this required a dedicated person. One of the ideas was identify a person that's a dedicated person to do this job, to manage this response. Have them empowered to make decisions and have core groups that were focused on epidemiology, laboratory issues, communications, the safe burial practices. Just try to figure out, what is it that we're trying to do here? Are we collecting the information and reacting to information that's relevant to finding cases, testing cases, tracing contacts, identifying where people go? How we're getting the messages out to them. How to handle dead bodies that may have been infected 00:56:00with Ebola because we're there and shortly after getting there, there were reports of individuals being buried and after having rained, the bodies coming back up, and how do you handle these potentially infectious dead bodies? Very chaotic and there was no systematic way of collecting information. How is information coming from the counties, which was the next administrative unit below the national level? There was a lot of focus in these Ministry of Health meetings on the county that the capital was in because that's where people live.

Like these very early days, I remember sitting in meetings where this is the national emergency response and they were talking about individual cases and 00:57:00individual management, "we should send a bereavement kit to so-and-so's house." It was striking because this is the person that's running the operations for the whole country and they're being inundated with very granular information and there needs to be people that can handle that for them. If they don't have the bandwidth to do that, that's where support from NGOs or international groups could potentially help. We made those recommendations and at the same time, Kevin made the point we really don't know what's happening out in any of these surrounding counties. We don't know the information that's being collected. Right now, we're having a hard enough time grappling with what's happening in Montserrado County where Monrovia is. We don't know what's happening in the adjacent counties. We don't know the quality of the information, how they're 00:58:00collecting information. We don't know the level of preparedness because there was all these infection control issues, and do they have appropriate personal protective equipment in these outlying--These were all the issues that Kevin was identifying that we just don't know what we don't know.

There was a disconnect with Atlanta because we kept getting the message, you're there to count the cases and help with contact tracing and we don't deal with the infection control issues, that's other. That's not what we were seeing on the ground. Finding the cases, you didn't even know where to look. You didn't 00:59:00know if people were looking for cases. You needed to get out to these other areas to find out if they were looking for cases. If they were looking for cases, you didn't know if they were actually reporting the cases because connectivity was so bad. I remember when Joe and Allison, I remember talking--I was e-mailing them as they were flying from--they came in after us. By that time, I kind of settled in this almost middle-management role where Kevin had said at one point, "They are the EIS officers. This is their experience, to get out in the field and learn this stuff." He was a huge proponent of training EIS officers. He was in these higher-level meetings and I was kind of left managing everybody and that's not really my training [laughs]. I was working with the 01:00:00embassy, sitting in these meetings at the Ministry, trying to organize their incident management system, working with the carpool to make sure that the EIS officers were getting to the motor pool at the embassy, making sure that they had transportation to get out into the outlying communities, and then following up with Kevin at the end of the day to make sure that we were providing whatever information needed to go back up through Atlanta.

In that setting, I remember corresponding with Joe and Allison saying, "As soon as you arrive you're probably--the next day or shortly thereafter--going to go up to Bong and Nimba Counties because we really don't know what's happening there. I'm arranging for your transport." It was pretty amazing. At that point, people would come in. There was no real briefing. There was this elaborate process that would subsequently be built in, but we'd get the vehicles, we'd get 01:01:00people in a car. There was like a once-a-week briefing by the RSO [regional security officer] and it was much less structured and I think Kevin described it as we're making it up as we go along because we just didn't know what else to do. Again, this idea of we can't wait to make decisions until we have all the information because we just didn't know where all the information was to be had. These guys were going out into the counties and we would get these periodic reports. There's no bleach left in the entire county. People have no gloves. We're hearing this stuff and there's no resources, so it was important to 01:02:00communicate this information, but there was a sense that we were doing things that were not necessarily in our lane--at least when we would report some of this information back. That's the perception we had. This was like falling on, not deaf ears, but why aren't you just counting the cases and getting the Epi Info module up and running?

We're hearing hospitals don't have enough practitioners. Hospitals are shutting down because there were cases of Ebola and the clinicians and nurses, some people would get infected and then no one would come back to work or the staff were being stigmatized. It was just a very chaotic environment. There was a 01:03:00staff team member, she came down and she was there specifically to help set up the Epi Info module. We sat through this training where we were going through and you're looking at the case report forms that would come in and they were completely devoid of meaningful information. People were not filling it out completely. You started realizing that no one--spelling of names, it was all phonetic and so there was no way to know. Some people would transpose first and last names. There's no hard and fast age because a lot of people didn't know how old they were. There's all this demographic information that's supposed to link people, but really the case report forms looked like they weren't meaningful 01:04:00information. People were collecting them and sometimes they were collecting them multiple different times because a county health person would collect this information when they would go out and do a case investigation, then it would get re-collected when the person showed up at one of the ETUs. Is this the same person? Is it a different person? It was not meaningful information. It was very jarring. Why are we doing this? What is the purpose of this when people don't even have the resources to safely care for these individuals? There's no actual bed capacity to care for Ebola patients because there's only two ETUs at that time and I think they both had like a ten, twenty-bed capacity.

What was the point of doing contact tracing on a daily basis when the Epi Info 01:05:00module would spit out like hundreds of pages of materials? And the contact tracing teams would come in and they would wait as long as they could, but then they had to begin their activities because the contact tracing forms would take hours to print up because there were so many contacts. They would go out and they would interview people and they would ask if anyone had symptoms and even if they did, there was nothing they could do. People would keep going out day after day and it's like, do you have symptoms? Yes. Eventually, people would die and they couldn't even remove the bodies because there was no place to put the bodies. There were no ambulances that could come out or vehicles to take dead bodies out and there were not enough teams to do this work. There were gaps at 01:06:00every level of human capacity, equipment like vehicles, personal protective equipment, bleach, and that was in ETU beds. So, you find somebody with symptoms, where do you put them? There's no beds. Hospitals are amplification points because they don't have enough personal protective equipment and then other hospitals are just shutting down because people don't want to get infected or clinicians don't want to get infected and nurses don't want to get infected. Liberia already had one of the lowest number of clinicians per hundred thousand people or whatever the metric is.

At the same time, once we got there, there was like these emergency declarations 01:07:00were being issued by the president [of Liberia]. Schools were being closed. There were threats of airlines not coming to Liberia. There was just a cascading series of events. ETU workers--of the two ETUs, one of the ETUs in Monrovia, had two American health workers. Unfortunately, they acquired Ebola. So in this setting of you were just watching things just kind of implode all around you where there's just a sense of this is completely out of control with the team members describing dead bodies on streets. When Joe and Allison were driving back from Bong, there were literally dead bodies along the road. When we went 01:08:00out to Margibi and went out to Bomi counties, I went with Almea, we went to Margibi and I went out to Bomi with Allison. It was the same kind of thing where it's like, this is where we would put our suspect Ebola patient while we're working them up and it was like this small little room, like no bigger--probably half the size of this [note: recording suite is approximately 9'x11']. Well, what would happen if you had more than one? What are you going to do if they vomit or if there is bleeding? How are you going to handle these infectious materials? And there just wasn't equipment. The same thing in Bomi, they were 01:09:00building this little, small, small, little--that is probably the size of this room or maybe from this wall to that wall where there wasn't any dividers, nothing. It was just basically like a bus stand where--maybe twice the length of a bus stand and twice the width of a bus stand. They would just put people--the plan was to put people in this space until there was an ambulance that could take them to an Ebola treatment unit. At that time, the Bomi major--their hospital was shut down at that point because they had had so many Ebola patients--they were just trying to disinfect the place. We're walking past this little shack that they were building and you see one of the ambulances they 01:10:00have, there's no wheel. They kind of lifted it up on a jack and that was like a consistent--what I saw in Bomi, what we heard in Margibi. It was the same thing. We don't have this, we don't have connectivity, we can't get information, we don't have ambulances to go out to places. We don't have fuel. We rely on--if there's a patient that needs to be transferred from one place to another, we rely on the transport from an adjacent county. This was not a matter of just counting cases and tracing contacts. We needed to take like ten steps back and say, everything is broken, and that message wasn't initially resonating.

Q: Do you remember any particular conversations with anyone where you remember this is just not resonating?

PILLAI: When somebody got basically a correspondence saying, we don't do infection control. Well, that may be the perception, but that's not the reality. These people are dying because they don't know infection control. The disconnect when we started getting additional staff and fortunately, it was Tai-Ho Chen who came out for the exit screening--but again, a perspective--seems even today, it's a little strange. It's important you don't want to export cases of Ebola, 01:12:00but it's one component, but there's many other things that need to happen like ideally we prevent Ebola from spreading. Tai got there and he got it immediately. Thomas George came out with him and the team started growing. Thomas and Tai were like okay, well, we can set up exit screening, but what do we do if someone screens positive? There's no place to put them and if someone screens positive, are we going to send them to an ETU? We don't even know if they have Ebola. At that time, what would happen is there is a ten, twenty-bed capacity, but the ETUs were overflowing with people. You had suspect people that could be potentially mingling with confirmed patients. It was really kind of 01:13:00scary. You didn't want to get sick because if you got sick, remember, one of the words like as we were walking out the door, if you got sick, there's been a lot of back-and-forth about where you would go and whether we would life-flight you out. The plan is you would go to the ETU. That was what we were told I think, like I was picking up my equipment at the EOC.

After getting there, I don't want to go to that, there's no way. It's just overflowing with people. There's concerns of, how did individuals get infected? It was this very surreal kind of environment. It was raining a lot. Kind of this overall oppressive atmosphere. The radio was constantly on just talking about 01:14:00why is this happening, where did this come from. There were jingles playing all the time on the radio about Ebola and it was pervasive. Signs on cars, people wearing these ponchos with Stop Ebola, Ebola Must Go, but there's no plan on how to make it go. A lot of angry, increasing anger. You could hear it on the radio. After getting there, angry family member setting fire to that room that I told you that had hundreds of people milling around--there's no kind of purpose to this meeting, but it was like the daily coordination meeting that went on for hours. Somebody piled up all these plastic chairs and set it on fire and that 01:15:00was the day Kevin and I were trying to meet with the minister of health. We had sat down in his office to go over the new, what we proposed would be the coordination or the incident management structure, which he eventually signed off on, but just a couple seconds after we sat down it was basically, his assistant ran in and said everyone has to leave. We're just running through this building that's billowing smoke. I still don't know to this day if it's true or not, the person that set fire to the building, they apparently caught up to him. He basically told them that I have a family member that has Ebola and everyone just kind of jumped away because of that because they didn't want to get Ebola from him and then he ran away. I don't know whatever happened to that individual, but it's just a really strange sequence of events.

We felt like we had a mission where we have to figure out what's happening. There's no systematic collection of information. We need to know what's happening in all of these counties. Are they similarly lacking in personal protective equipment, infection control guidances? How are they collecting information? Do they know how to do case identification? Do they know the case definitions and how are they collecting this information? Going out to the counties to basically set up Excel spreadsheets to collect this information because it was clear that Epi Info was not cutting it. Throughout all this, they were still trying to stand up Epi Info and you'd go to the Ministry of Health 01:17:00and you'd see binders of forms that had to still be inputted into the Epi Info module because there's one computer at that time that you can enter this information into. There was stacks and stacks and stacks and there would be like half a dozen people in one room trying to enter this information and it just seemed pointless. I remember having those conversations with Kevin early on. I was like, this is not an effective use of time. We need to think about a different way of doing it. I'd like to think that that was prescient because a couple months later they were no longer trying to do that. Same thing with the incident management system, it did provide structure and it did end up sticking 01:18:00and they ended up using it throughout the response. It made me feel like okay, we did make some difference here.

It was really hard in July and August because things just kept getting worse. Again, things are starting to blur together now. Something in West Point, they ended up closing off West Point. I can't remember if they closed it off while we were still there or they were doing it the day that we left because I remember when we arrived in wherever we touched down, I remember turning on my Blackberry and there was this message that there were riots in West Point. There was this 01:19:00sense as we were driving to the airport, I remember thinking we're leaving, the next team that's coming in--which was much larger because by then, people started getting it. It's like, there's a problem here. They brought in more staff and they were more organized and I remember thinking to myself, this team is going to be, they are in for it. We're just starting to see. The teams like Almea and Joe and Allison and Jen and Patrick, they were the ones that were actually going out and hand collecting the information from the counties and getting the data. Epi Info wasn't particularly cutting it. It was just like this hand collection of data from the counties and you just saw this upward trajectory and again, that was deceiving. So great, you have bar graphs and 01:20:00numbers, but you could see the manifestations in everything else. Bodies are on the street. People are screaming for answers and it was just like hospitals are shutting down.

There was clearly a problem. We went to the ETU the day that we heard about the infections, Jen--

Q: Which ETU is this?

PILLAI: This was the one in Monrovia, ELWA [Eternal Love Winning Africa]. Kevin, Jennifer and I went there and we're doing this investigation. This is an example of how we just inserted ourselves. Kevin just basically said, we have to do 01:21:00this. I guess in retrospect, should that have been the Ministry that led that? I don't know, but we said we have to figure out what's going on because this is going to have huge implications, like if ETU workers are getting infected, there's only two ETUs and there's not enough healthcare providers in Liberia. We have to figure out what's going on, otherwise, people won't continue to come to help support activities here.

Q: What did you find at ELWA?

PILLAI: ELWA was--it was pouring that day and I remember trudging through--there's a compound and there's a gate and it's just like a bar and some 01:22:00guy sitting at the gate. They're like, why are you here? We tell them and then we walk around and we just trudge through this mud and there are these stakes on the ground with boots upside down with buckets, like I guess bleach containing solution where all their PPE and work apparel are being washed, and wash lines that are strung across that just have their aprons are hung over it. This is the state of the art. We couldn't go into the high risk areas of the ETU, so we walk into this narrow little hallway and it's crammed with nurses and people that are 01:23:00on break sitting on these wooden benches. There is a blue tarp that's separating that area from the ETU proper. The high risk is just right behind it. You just see these nurses, they're drenched with sweat. One had just gotten out from a shift and I think it was a young man and he was just soaked to the bone and he had a multi-liter bottle of water and he just drank the whole thing in one fell swoop. They're completely dehydrated. They're working in this basically microwave oven. It's this tarp and a roof in that heat of West Africa, wearing 01:24:00all these layers of PPE. I was shocked. This is the conditions that they're working in and your heart went out to them. What can we do to help these people? That's where people were going for care. That's the conditions that the clinicians were working in. That was just in Monrovia. Patrick ended up going up to Foya and he had his own experiences up there where he had to flee into Guinea because of community unrest and we were sitting in--

So we were going to ELWA, Jen and I are sitting in the NGO's work compound, we're ready to go to interview some of the people that were in the ETU and Patrick, he had flown up there and I can't remember if he had e-mailed. It was very intermittent connectivity and I don't remember how he got in touch, but he was just like, call the embassy because they're burning vehicles, there was some sort of ambush or something. There was a community in the Foya area, in Lofa--that's the county name--in Lofa where there was a community where there was presumed to be a lot of Ebola infections and I think they had invited the health department to go in or some group to go in to kind of do an 01:26:00investigation. En route they kind of started stoning the cars, and I think they may have set the cars on fire. People fled and Patrick and the team there had gotten word that they were marching towards the ETU. We were trying to call the embassy to try to figure out okay, we have a first-year, second-year EIS officer that's basically completely inaccessible. It's like fifteen hours by car or like some sort of Land Rover that could actually navigate through that kind of terrain from Monrovia. What are we supposed to do? The recommendations are: shelter in place or try to get to a safe place. This is crazy. This is after the Ministry had been set on fire. We're working up the first Americans that had 01:27:00contracted Ebola working in an ETU. And then curfews had been set, schools had been closed and now we're trying to figure out how to safely evacuate a team member from a place that none of us are going to get to anytime soon. He and others drove up to the border with Guinea, got on dugouts and rode over into Guinea until it was safe to come back.

This is another example. The person that drove them up there, he was an embassy driver. He drove them, but he didn't cross over. So these people were putting 01:28:00their lives at risk for us and I remember thinking that as I was leaving in the middle of August. These are the Liberians that are working with us and helping us, the embassy drivers and embassy staff and all the people that we work with. The people at the hotel--these people, they live here. I get to go home, they don't and I was thinking about that. They have families. There were so many reports of people getting the cabs there, they would just cram all these people into the cabs. It's not like I would get in and say I want to go somewhere. It's like, if anyone flagged them down, they would pick up another fare and keep 01:29:00going. There were multiple reports of Ebola patients just getting in a cab and then just trying to get to the hospital and dying as the doors opened. One of the drivers was like yeah, I go home, I catch a cab at this place and then I go on and then get another cab. My gosh, these people live in the midst of it and we can kind of escape.

ELWA, I'll be honest, when I got there it was pretty overwhelming. I was like, what are we doing here? It was a four-week deployment and I felt like okay, the first couple weeks, first one to two weeks I felt like at least I had accomplished something by getting that incident management structure in place 01:30:00and it took a while, but I felt like I had accomplished something. What am I doing next? I remember they wanted these contact tracing trees developed--I'm like, this is ridiculous--using the Epi Info module. I can't in good faith ask the EIS officers to do this because this data is garbage. I remember spending days working on it. It was completely meaningless. At the same time, we were developing this compilation, this report from the various counties of what their resource needs were. What they were doing. I felt like okay, this is probably important too because it's not like case counting and contact tracing, but it's at least setting up a--it was the needs or the gap analysis. I think that's what 01:31:00we were calling it, a gap analysis, so that we can tell somebody this is out of control and we need more resources. At some point, I remember I was covering for Kevin on some call and we'd sent this report up and at some point, Dr. [Thomas R.] Frieden was now getting on these calls too because I think it just started getting elevated to his level. Maybe it had already been, but this is one of the first times I was on this call and we have our gap analysis from X number of counties and we're still working on it. He was like "Oh, well, can you share that with me?" I hadn't interacted with the EOC leadership or CDC leadership and 01:32:00I'm like, "Sure." He was like, "You can just send it to EOC Report." Whatever the--I was thinking to myself, has anyone told him what we've been telling people in the EOC for weeks now? I was more than happy to send it up, but it made me wonder. Maybe they just don't get it.

Q: What was the specific document that he was asking for?

Q: It was a gap [analysis], county-by-county of the counties that we had visited. What their demographics were, what we knew at that time of their case counts. Data that was being collected at the Ministry level, we didn't know if it was even accurate, so what do the counties say their reports were? The number of cases?

Q: This information is kind of garbage still, is that right?

PILLAI: I think at the Ministry level, I didn't trust--I think that's safe to 01:33:00say. It wasn't reliable. We would go out and these guys would collect the cases, they would find out how information was being collected about cases, how contact tracing was being done, what were their resources, how were they conducting infection control and how many facilities did they have in their jurisdiction. Had infection control training been done. What their resource needs were. All this information was being collected in a semi-systematic way, but it was more than what we could tell anyone else had done. We did that and he sounded very eager to receive this information. I'm like hopefully this leads to something good.

Simultaneously, I remember having conversations with one of my colleagues in my 01:34:00home program, I was like, what exactly are they doing in Atlanta for the infection control and global migration? Because this is before Tai had gotten there because I remember like from my MERS experience, it's a small world and it's only an amount of time before someone gets on a plane, and there were all these infection control concerns and airplane screening concerns during MERS. Are they looking into that? And shortly thereafter there was this Liberian gentleman who got on a plane and went to Nigeria, and I think that's when there was this big concern about spread of Ebola out of these three countries and into Nigeria and then kind of accelerated the concern of wow, if it gets into Nigeria and spreads widely that would be really problematic.

I think there was increasing focus on some of these other non-traditional, 01:35:00outside of what was typically done for these outbreaks because they're typically smaller, typically in very rural areas and here we were seeing something very different. It was in this urban area and it was multi-country and it was just spreading all over in very mobile populations. Like you would hear histories of people traveling all the way down the country seeking care, riding between counties, just trying to hide the fact that they had symptoms. Again, people not wanting to go to the ETU because you would get in the counties that did have ambulances or they were able to get transport, all they heard was the person got in an ambulance. There's two ETUs and let's say you live not anywhere near that, 01:36:00if they finally come to get you and you go off to this ETU, there were very high mortalities and you may never hear from your loved one again and you never see them and you never hear from them and then they die. Why would you go there because you're going to die? It was very--it was surreal. They didn't have a good laboratory system. Their lab was an hour or hour and a half outside of Monrovia at LIBR, Liberian Institute for Biomedical Research. The lab that supported the ETU in Lofa County in Foya, that wasn't even in Liberia. That was in Guinea, in Gueckedou, so they had to transport specimens by motorbike across 01:37:00the river and into Liberia.

The lab in LIBR, when we went out there, you realize that they didn't have a system in place. They're like well, you tell us what you want. I'm like, this isn't a research lab, we need to have timely reporting of results because that has huge implications. If you're a suspect patient that rules out, you can get him out of an ETU and away from a person that potentially has Ebola. I remember sitting there building this. Patrick and I went out there and just showing them, well, this is how--this is the spreadsheet that we would use. This is like what 01:38:00American USG [United States government] partners that had come out, but they were research laboratorians. They're not used to clinical reporting. It was a paradigm shift--they had gone from Ebola seemed to be this kind of boutique disease that had very few people studying it and it was in these remote locations and there were researchers that were interested in it, small number of public health practitioners, so you can keep it small and not have these elaborate systems created or have programs like Epi Info, VHF module, which weren't meant to be used for thousands of people. When you're talking to these highly accomplished researchers, they weren't thinking of having, well, why 01:39:00would we need a reporting system to handle hundreds and hundreds of tests per day? That's not what we do, but that's what you needed.

Q: And how did they respond to you trying to bring this new paradigm?

PILLAI: Some people were understanding, others I think--it's different. You have to tread cautiously. I remember sitting there thinking, I'm not the expert. I'm not a laboratorian. I'm telling you what, if I were the one trying to receive this information, this is what I would want to know. This is why I would want to know it. Again, you're building it on the fly in an emergency situation. You're trying to do the best you can. You're using whatever experiences you've had in 01:40:00the past--clinical experience, past experience. You know that there are resource limitations, so you want to make it as simple as possible that has the core amount of information, and that's I think each and every one of us came to that conclusion probably independently, whether it was Tai with the exit screening stuff or the EISOs [Epidemic Intelligence Service officers] and when we went out to the counties. How are they collecting information? Make it simple, make it fast, make it efficient. If it's a matter of Excel spreadsheets and calling in your numbers and calling the Ministry of Health or whether it was the laboratory reporting system, keep it simple. What is the simplest way? At every step of the way, you couldn't imagine the number of road blocks and land mines and 01:41:00challenges. Well, we're out in a place that has zero internet signal and cell phone reception is terrible out here. So, how do you get the information from LIBR back to Monrovia?

During this whole time it's like--we would have our discussions, who could potentially do this? Who has this kind of organizational structure where you could get mobile labs and immediately set up cell towers and connection and move supplies, large amounts of supplies from one place to another, securely without getting looted or stolen? Everyone kept saying the military could do it and it kept coming up. That was crazy. It's not going to happen. Eventually, when the DART [Disaster Assistance Response Team] folks came to Monrovia, I'm not quite 01:42:00sure how they were activated, but they came and they had this liaison person who was civ-mil [civilian-military] liaison and their job was to have that kind of discussion. What kind of resources? And I remember having this discussion with her, saying "We can't do this. We can't get information on a timely basis from most of the country because we just can't connect with them. Is there a way to improve? We can't get laboratory data. There are huge parts of the country that just lack any resources, running water. Is there a way to get supplies like personal protective equipment, bleach? Is there a way to set up mobile treatment tent kind of places where you can just put them out there and staff?" You're 01:43:00trying to pull patients out of the general population and out of the hospital population that have Ebola and could be spreading it to other people. You want to pull them out, so that they're not ongoing transmission.

I'm having this conversation and there was all these reasons well you know, the military is the last group that you go to because if it's not in their mission and there's cost issues and whatnot. I was like, I don't know who else can do this. You can't get enough NGOs here fast enough and at that time, there weren't people flocking to Liberia. It was kind of a very strange experience. Like the 01:44:00call center, there was one call center. Hotline. It was the national call center and it was run out of JFK Hospital [John F. Kennedy Medical Center]. At that point, it was completely closed, there was nobody there. I can't even remember why now. Had the government shut all the hospitals down at that point because there was so much, briefly, or if they had closed themselves--I can't remember. The hospital was basically empty. The pediatric ward was completely empty. The pediatric waiting room, I remember walking through it and you're walking down 01:45:00trying to get to the call center where people in the community call and say I have a suspect case, blah blah blah, and then they would triage the call and send it to someone that would dispatch an ambulance or case investigation team. I believe his name was Arthur, he was the one that was in charge of the call center. Literally, this room from here to here.

Q: Maybe a quarter of the size of this room?

PILLAI: Yes. They had this one light bulb hanging from overhead. There's three people in there already. I walk in and we're just crammed together and they're just handling calls and it's just these three guys and I'm like, this is crazy. They're writing down these notes and then the power goes out and then there's no 01:46:00light. To even get to the room, it was bizarre. It was like walking through some sort of jail where there were these huge metal bars in front of the doors so no one can break in and steal stuff and these dark hallways. And then you finally get to the call center and it's this shed and these guys that are working, Arthur was just working seven days a week. He always was doing this. But you would send a case investigation team, case investigation team might go out. Then they get information, but if they needed someone to come out and take the person to the ETU, that's a different group, the ambulance. And then if you needed someone to come out there and disinfect the place, that would be yet another. You'd never get all the people there, all at the same time. There was all these issues of efficiency, coordination, supplies and then if one of them didn't have 01:47:00a car, like one of those teams didn't have a car, no one would go. Not enough vehicles, not enough gas and at the Ministry when you see all this coordination, you would see people that you would think they're mundane things, but there's one person whose job was to sign for if someone needed gas because there's just not enough money to go around.

Allison, I remember she had gone out to Margibi I think at some point where there were so many infections that the hospital shut down I think. The ones that remained, they were locked in the hospital. Family members were angry because their loved ones weren't being fed. They were basically in this place, locked in 01:48:00there and the health department just didn't come. They were decimated and Allison I think was the only one there. She's sending text messages, we need this, we need that, and I just remember there was this back-and-forth about the supplies. I'm like, they need a thousand pairs of gloves. The person there just wrote this little note and gave it to someone to go okay that purchase. That was what we had been reduced to. We had gone there counting cases, helping set up this database, but we were literally at the level of trying to procure resources to get them from Point A to Point B and just identifying issue after issue after issue and not having any kind of clear, sustainable idea of how this was going 01:49:00to be fixed. Conversations about what do you do for patients that may have Ebola, but you have no place to put them, no clinicians to care for them. This idea of transit centers came up where there's minimal--clinicians wouldn't necessarily touch them, they would provide food and water, antipyretics. But the idea, the clinicians--that they'd already had so many deaths that the number of clinicians was like this precious resource that you didn't want more people to get infected. You didn't want IVs, so these ideas were being discussed. Are there intermediate levels of care? Again, that was based on these crisis-like 01:50:00conditions that people were seeing on the ground, but again, Atlanta just couldn't wrap their head around well, why would you ever do that? That's not standard of care, and I think the idea was we are not in standard of care. We're in a situation where we're seeing this kind of society just implode upon itself.

Q: What's it been like just talking about this for the last couple of hours?

PILLAI: I can't believe I've forgotten some of the details that I have. I feel like I can probably talk for several more hours. [laughter] I feel like I'm glad I can talk about some of these people that I worked with because they meant a 01:51:00lot to me. They did so much and I'm really grateful that I had a chance to work with them. They're very special. It probably sounds odd, but they mean a lot to me because I feel like I think what they did was pretty amazing.

Q: Thanks so much for being here. Would you be open to another session at some point?

PILLAI: Sure.

Q: That would be brilliant.

PILLAI: Well, thank you so much.

Q: Thank you.

END