Dr. Seung Hee Lee

Dr. Seung Hee Lee

Q: This is Sam Robson, here with Seung Hee Lee-Kwan. Today's date is April 4th, I believe, 2016, and we're here in the CDC [United States Centers for Disease Control and Prevention] audio recording studio at the Roybal Campus in Atlanta, Georgia. This is our second interview speaking about Seung Hee's experiences with the 2014 Ebola epidemic response. Seung Hee, we have a list of interesting topics to talk about. Just dive in.

LEE: Sure. From previous interviews, I tried to depict my role in-country in Sierra Leone, in Bo and Kenema Districts. My biggest mission in developing health promotion or health communication strategy was to find something that's relevant to the locals, because that's the best way to communicate urgency with locals, if you can resonate with them. After talking to many local leaderships, or just like hotel clerks or drivers or market store people, I said, okay, I 00:01:00need to make sure that--this is a very desperate time. Is there something that could get people to perk up, or get it right away when I use a certain analogy? And I asked them, you guys just went through civil war, what was it like doing that? How did you guys do burial? I know burial is really important, but during wartime, come on. Bullets flying around, how did you do all the washing rituals and things like that? They said, but wartime is different, wartime is special, wartime is different. I was like, oh. So if I say Ebola time is like wartime, would people get it? They're like yeah, it's a really good way, because everyone in this country experienced it one way or another, just like Ebola. Ebola, people are experiencing it one way or another. It's either your friend or your neighbor or your family, your relative, someone you know. Your schools are 00:02:00closed just like during the wartime. People are stigmatized from the war, too. It was a really good analogy to use, and I thought that was just brilliant that people recognized similarities. But then people were telling me, even in wartime people took drastic measures when it comes to burial because it's so important to them. Like I said, I was in Kenema, more towards the east side of the country, so when the war happened from the mountainous areas and it was coming closer to Freetown, whoever died--like let's say one of the interviewee's fathers died from gunshot. They buried him, but they made sure where the body was buried. They used special plastic covers--they had some markers so that they 00:03:00could come back to retrieve the body and then give him a proper burial at their community. I said, but then you can't clean the body because it's probably decomposed. What can you possibly do to the bones? They said, there's a spiritual way of doing it. Okay. At that time I didn't really connect the dots. I was like, okay, there's a spiritual way of doing it. I didn't think much of it. But as I hear this concept of spiritual cleanse, I came to get really curious if it's something we can do with a fresh dead body.

I only learned it after I left country. I still had good connections with--I can't remember the NGO's [nongovernmental organization] name, but an American 00:04:00who worked in a local NGO for a couple of years. He had community members educating and sensitizing rural villages around the Bo District. And one guy who did a lot of qualitative research came back with quotes from one village that he interviewed. The village leader said, quote, "We understand that this is a serious matter, Ebola is a serious matter. We're going to take it as a community approach. All death will be done by proper medical burial, and once this flare dies down, we as a community will have a purging, like a cleanse, a spiritual cleanse, for the entire community." Because of all the sin that they have done 00:05:00by not washing the body, the entire community will go through a spiritual cleanse led by religious leadership of that village that does not involve touching, that does not involve washing the body, but still understanding the value of ensuring the loved ones make it to the painless eternal land, afterlife. And I thought that was such a great example that can be possibly disseminated to different areas, because ultimately what locals want is to make sure that there's completion to one's life that's not destructed by foreign power or disease or what-have-you. I thought that was something that I really wanted to share with this interview, that ultimately, we did find ways to 00:06:00comfort the locals, yet doing what's right for public health. So that covers the first two topics.

Q: Can I ask, was that a message that you were able to repeat among other communities that caught on at all?

LEE: By then, I had already left the Ebola response, but I did make sure to channel that specific piece of information to those who were in-country. I think by then, we're talking November, December, so Port Loko, Bombali, they had a surge in outbreaks. And then, simultaneously, we had more resources. There were more ambulances available, so there were less likely to be incidents where bodies are left with the family for forty-eight hours and no one can come pick 00:07:00them up. I think it was more rapid in that regard, so we didn't really have to worry about people going out of way and washing the body because no one's coming to pick up the dead body if there's a faster response. Also, there was quite a bit of commitment made by very important people in-country saying that if I die, I want medical burial. That kind of pledge was done, and I think over time it gradually changed people's perceptions about medical burial. But then again, having that piece of information is really helpful when there's resistance. "Oh, and this other community, they did this kind of community approach by doing the spiritual cleanse and the entire village took it as a whole and did this thing, because there is a way to still clean the body that way." I think it's always 00:08:00good to understand that, and I was personally interested and I wanted to make sure that I followed up with those who were successors who came into country after I left.

Kenema was a really interesting place because they experienced the Ebola outbreak much earlier on, like June and July. The first case from Guinea came into Sierra Leone in May. Kenema had a Lassa fever lab, the only one in West Africa for that matter, and Lassa fever is also hemorrhagic fever, and so they had a lot of experts there. When I went to Kenema, the famous Dr. [Sheik Humarr] Khan, who was an expert in hemorrhagic fever, had died. One of the lab 00:09:00technicians and people who worked for him was there. His name is Michael, and he actually went to the very first case's village, the village where the first case in Sierra Leone had occurred. He interviewed the locals and documented what had happened. They were the ones who actually performed quote-unquote "safe burial" with some very minor level of PPE, with gloves and what-have-you while the community is watching, because it was the first case and they weren't sure it was Ebola but they took precautions and what-have-you. He told me that the locals believed the first case had died of witchcraft, some level of curse, and that the wife had a black snake in a plastic bag and then the husband opened it 00:10:00and the black snake was the curse so that the entire family got it. You know, that sort of witchcraft kind of story. But it was really nice to hear from him what it was like to be like an investigator of this unknown disease and how scared he was not knowing. He lost a lot of his colleagues, those who worked in the Lassa lab and what-have-you, but he also shared the sentiment that no one really listened to him even though he was out there in the field. Those who actually listened to him were like BBC reporters or Washington Post. Those were the ones listening to him, and not the ones who are actually running the response countrywide. So he kind of shared that sentiment and I said, "You know, you can share your information with me." He had a wide range of pictures, and he 00:11:00was willing to share it with me because I treated him with respect. I said, I will not share it outside the CDC parameters, but I think some of these pictures really show what it was like in the beginning. Like it really shows what it was like before this Ebola outbreak was declared, how the burial was done, because we don't know. We're outsiders. The picture that he--showed that funeral was a community thing. The entire community would grieve, and showing grief was an important one and some of the pictures actually showed that males would go inside the grave and three males will be inside the dug-up hole, carrying the body that's been wrapped with a white shroud. But then there was a cloth that was covering the body. The youngest child is supposed to wear that cloth and grieve in the corner, so there could've been bodily fluid contact in that 00:12:00regard. People who come to the funeral are supposed to put some sort of rock in the water that the body's been washed, so there could've been, again, some level of contamination. Looking at the pictures made helped me see, like what I read, now I have a cross reference with actual pictures of what was done, and him being an infectious disease expert, taking precautions, knowing all those kinds of things and telling the locals these are areas where transmission can occur, you guys should really take care of yourselves and blah, blah, blah. So I really wanted to mention his expertise really helped out the Kenema team because we would always ask him, what do you think about this, what do you think about that? And the Kenema office was really small. The Kenema office was within the 00:13:00compounds of Kenema General [Government] Hospital, where there were--when a suspected case comes, we would make sure whether or not that person is actually an Ebola patient. If they are, we'll send them to a proper treatment center. We were just like ten, twenty feet away from that, and it's just a wooden structure, and we've been told people escape from that. If they wanted to, they can. The wooden fence is already all broken, but when we actually walk around that wooden fenced compound, you see notes written by patients or suspected patients who were inside the compound that "I will leave here alive," you know, with pen it's written on the wooden picketed area. That kind of made us feel 00:14:00really special, that we are here real time and this is actually happening. The office was in a very poor environment. We didn't have A/C [air conditioning], we barely had electricity. We needed to have like a separate generator, and it happened while we were working there because we couldn't share the hospital's generator because that's all money, right, and you can see all kinds of medical waste just flooded around, needles are here and there, and be careful. Always had to wear shoes covering our toes because God knows where that needle has been.

One very traumatic event I had was there's a dog named KG. Kenema [Government] Hospital, KGH, that's the initial, and there's this little puppy, everyone called him KG cause he's in Kenema [Government], and apparently a lot of dogs 00:15:00died because families died and they didn't feed the dogs and what-have-you. But that dog apparently was a symbol of hope in Kenema [Government]. We all loved the dog, sure, but God knows where this dog goes. In the Kenema [Government] compound, we've seen a lot of burial teams taking off, donning off their PPEs [personal protective equipment], their goggles and what-have-you, and they're supposed to be disposed of properly, either buried or burned. There was a big dumpster, if you will, and part of it was burial team goggles and things like that. And KG can go there, and KG brought back goggles of unknown origin and he 00:16:00was chewing on it. Super cute, of course, so I took a picture of it. It's bad infection control, right, because then a child can play with the goggles. We assume that it's been sprayed down with chlorine, but you never know, so we needed a better protocol. They needed to dig a deeper hole for burying something like that. So I was documenting that, and KG, so happy to see me, jumps up and bites my hand out of excitement. [laughs] I'm swearing, and I run to the chlorine and opened the chlorine water, because there's no running water, it's all just a small container. Imagine like at a sports event there's a Gatorade or water dispenser. That's how the chlorine was, and we washed. I gulped it open full-blown and dunked my hand in there for like a good minute because I was so 00:17:00panicking. Thank goodness my EIS [Epidemic Intelligence Service] classmate was there as epi [epidemiologist] in Kenema, Kimmie [Kimberly] Pringle, and she was an ER doc [emergency room doctor]. It's a great place to be deployed with an ER doc. She's like, "It's okay, let me see if there's a puncture, because if there's no puncture, you should be fine." But my gut reaction was it bit me and it's a puppy, and puppies have really sharp teeth as opposed to dogs. After they lose their first teeth, they're more round. She inspected my hand and she said, "There's no puncture wound, you should be fine." But still, I saw what KG was chewing, so there was a little bit of scare there. I told my husband two days after when I felt fine, you know, forty-eight hours after I was like, "KG bit me," and he was so upset. He was like, "Are you sure you're ok?" I'm measuring 00:18:00my temperature three times a day, there's no fever, I think I'm out of the woods. But yeah, to this day he's like, aaagh, KG, bad dog!

[interruption]

LEE: Do you have any questions about KG? [laughs]

Q: I know you were only there for a limited time, but did anything come from reporting [that] this dog was able to access this medical equipment?

LEE: That was not my expertise. I reported to infection prevention and control, IPC team, and they were in fact making rounds to like Bo, Kenema. They were going to different districts to make sure--do IPC training and also observe what was going on. They did see--I think they probably recommended what to do, for the infection prevention and control team to do. Again, it's just my observation. I don't know what happened afterwards, but there were experts 00:19:00coming in observing, monitoring, and trying to make adjustments so things like that don't happen.

Kenema's hotel was a very interesting hotel compared to Bo. "Hotel" is a very grandiose word for a place like this. While we were there though, we communicated with headquarters in Freetown that we had very little--were not connected. And actually they sent out experts, e-Health [Africa] I think, who are locals in Africa who contract with CDC, and they actually came to our hotel to set up internet speed issues and whatnot. So that was pretty cool.

The lady who actually takes care of this hotel, we got really close because I 00:20:00asked her about a lot of secret society things. I asked her, "What was it like for you?" She said she was so afraid of the initiation process. She kind of hid, like she would hide. But she ended up getting one when she was thirteen, which is much later than most girls become part of the secret society when they're like eleven. She would hide around her birthday so she doesn't get plucked to go to the initiation process when she was thirteen. And then she said she had the worst time healing. So she doesn't have a good experience, and she was the one lady who told me she wouldn't let her daughters go through with it because it was so painful for her. I said, "But I heard the other side of the story where 00:21:00you get to learn how to cook and all the good things. Tell me about that." And she said it really varies by--she didn't use the word "tribe," but like different regions will do different things. I guess the part of the group that she was involved with were very aggressive. She would share like the boys--not only do they get circumcised, but they would also basically tattoo-equivalent with a needle on their backs, and the more you can bear pain, the more valued or cherished you are. Oftentimes I would see guys with some sort of scars on their backs. I thought it was like whip marks. I was like, were they slaves or something? But no, it's actually intentionally done on their backs with needles 00:22:00like threaded through to make it look like a tree or a wind shape or what-have-you. That was really interesting to hear from her because she was the one who asked, "Do you want to be part of our secret society? But we have to initiate you." I think she was partly joking. I had to prove it to her that I don't need to be initiated but can be still part of the secret society by dancing in front of them with music. We were all dancing in circles for like a good thirty minutes, and it was good bonding. All the ladies from the hotel came out--who did my laundry came out, and she started clapping and laughing. And danced, and then I said "I'll cook for you because I can cook." So I cooked for them, too, to prove that I'm worthy of being part of a member and I can skip the 00:23:00initiation. There's one girl who cooked for us, for our team, and one day she had black and blue on her eye. So we noticed that domestic violence was also an issue in the area and people really don't talk about it. As a woman, I thought that was also interesting as an observer, like things like that happen, because one of the big signs that we saw was a very aggressive picture of men hitting women and like, "Don't do it," like "If you see it, report" blah blah blah, as a public announce--you know, PSA-type [public service announcement] thing--very frequently around the country when I was driving around. So it was kind of heartbreaking to see that. Not related to Ebola but still something I noticed.

Oh, in Kenema they gave me a gift as I was leaving them, and it was a very 00:24:00special gift because it was clothing that local healers will wear. They said, don't wear it. And I did actually donate it to the [David J Sencer] CDC Museum. They said, you cannot wear this in the village because then the local magician, healer-magician equivalent, whoever has a lot of spiritual power, will find that very offensive and will take it as like a throw-down, and then you guys will have to do like a black magic throw-down to prove who's more powerful. So they're like, don't do that because he will think it's a challenge. I was like, oh, okay, I won't do that. But one of the stories I heard, the local spiritual healer--there could be many but apparently there's a best one, the most powerful 00:25:00one in the community that everyone knows. This person will start playing the drum, a wooden, small, handheld drum, and starts beating it, and then all the people will come and confess to him. Apparently, that's the magical power he or she has. What kind of confession are we talking about? So a man would come and say, I've been witchcrafted, I cheated on my wife. I've been witchcrafted, I did this. So they would come and talk to this very powerful man, and that's how the village is run. Then the healer can cleanse you and treat you and help you. Let me get the witch out of you so that you can go back to your wife, for instance. So I said, "Can I wear this and start playing the drum and say, 'Anyone with 00:26:00Ebola come out,' or 'Anyone who had contact with Ebola must come out?'" And they said, "You can, but then you have to go through him, the original healer, and then you might die because he will suck out all the spirit from you and you don't want that." I thought that was really interesting.

I asked a group of very intelligent people who are like health educators in the community, "How many of you believe in witchcraft?" Everyone raised their hand. And I said, "How many of you think your people believe in witchcraft?" Everyone raised their hand. And some of them explained it to me like, we've seen it done. "Eighty percent of the time I believe in black magic, witchcraft. But my people, one hundred percent of them believe it." So I said to them, "What are the 00:27:00communication approaches that we can take when people think it's witchcraft? How can we give them the right information?" And they said, "You have to have a trustworthy person talk to them and show them and demonstrate"--and I told you before, when we use the egg example as direct contact with a virus--like, the egg doesn't become a chicken the next day, right? We had an egg picture, like egg, egg, egg for twenty-one days, and then it becomes a chicken. We kind of explained it to them as having direct contact with Ebola virus, say from vomit or urine or spit. Just like an egg becoming a chicken, it will be infecting your body, you just might not feel it up until twenty-one days, maximum of twenty-one 00:28:00days. Some people might feel very sick in two days, some people might feel very sick on the tenth day. At that time I think the average was like four to seven days; twenty-one days were very rare cases, but it had happened before, so we're saying twenty-one days. "That's why we're keeping you quarantined for twenty-one days because it has happened before." Using that kind of example helps laypeople understand better. That was one of the interactions I had with Kenema health educators. In Bo, one of the sensitization efforts led to me getting a marriage proposal, a ninety-some-year-old village chief wanted me as his fourth wife. A couple of days after that, the Bo mobilization team got me this beautiful purple 00:29:00dress, a local African dress, and they really wanted me to wear it. We took pictures, and again, that dress is also donated to the CDC Museum. Everyone started making fun of me because everyone who were at the village sensitization knew that I got this marriage proposal and said, "Oh, are you getting married? You look beautiful." My CDC friends were making fun of me. It was good memories around that.

Around that time, I was planning on coming back, which was like November 4th. About a week before--leading up to that, there were a lot of issues domestically here in the United States with a new Ebola case here, and Kaci [Hickox] just returned and a lot of the people that I worked closely with who were in Bo were 00:30:00lab people who had just came back and they were asked to leave. One of the lab person's ex-wives was a teacher. She was asked to leave, some of their children were asked to leave, go home. When we heard this story from other lab people, we were really angry how insensible some of these actions were and how hurtful it was for a lot of people, and we talked about that a lot here. I was starting to get cancellations of some of the talks I was supposed to give here domestically in Duluth. The conference leadership said, "I understand that it's fine, but people who are attending the conference wouldn't understand." And it was a scientific conference. I felt betrayed a little bit. I reached out to CDC folks 00:31:00here, and I think it was a time when this whole like support group type of thing was happening, or risk mitigation group was just developing, and they took my case and they tried to seek ways to help me out. It was really interesting how that dynamic had happened, and I came back and my husband and I had issues dealing with how to be back and live normal and not feel guilty that I am not there and I'm here. That took me a little bit to adjust, and finding ways to still serve while I'm in Atlanta.

I think that covers it for the most part.

Q: That was brilliant.

LEE: Do you think I missed anything? Do you want to know anything more?

Q: I think I had some inconsequential questions along the way, like when you're dancing to the music, for instance, is it people are playing the music or is it on a radio?

LEE: Yeah, we had it on the phone. One of the locals had music on the phone and it was local music and we were just circling around like a snail, dancing, and we were dancing out of that circle. But no touching, of course, so we had distance and we were dancing. It was good. It was so hot. We were all sweating. But it was also a really good bonding experience.

Q: My larger question I guess would be, listening to you throughout these two 00:33:00sessions, it's clear that you went to Sierra Leone and you really invested yourself in knowing about Sierra Leoneans' cultures and beliefs and what people care about. So I'm wondering if you see yourself making a longer term investment in the region.

LEE: Yeah. I keep telling my friends I want to go back, and the reason why I wanted to learn more about the country was because from my previous experience in Baltimore for my PhD, getting to know them and getting to know their culture really matters in long-term intervention efforts. I knew that already going in, so I really took my time to get to know these people, very influential people who will, I think, become leaders in the country. We still keep in touch and see 00:34:00how I can help. Like, I still review their proposals every now and then when they need my input, just for English's sake or just aesthetically, like you can make it prettier by putting in photos or whatnot.

Oh, speaking of, I forgot a very important one. The previous session, I told you about decapitation of the leader and putting it [the head] onto a new leader. You'll probably hear from a lot of other people about these wooden masks that people brought back, purchased. I knew about this mask because not always you would have a real person's head on your head, right? So symbolically, they make wooden masks. The way the female secret society leaders would wear these wooden masks that are basically a head--so a wooden carved head of previous leaders. 00:35:00And then each animal means something. Like, prosperity would be like an antler with really long horns, or a monkey would be something. So that a person's head, wood-carved head, wearing an antler head, wearing a money head, it would be a really long wooden mask. They'd wear it when they do a lot of initiation or dancing or rituals, etcetera. So again, I brought back a mask. I said, "I really want to buy that mask. Take me somewhere, let me buy the mask." So I went to this market. Of course, the market is dead because it's during the Ebola epidemic. No one wants to go to crowded areas. Everyone wants to up-sell me because I'm the first customer, I look like a foreigner. They were trying to up-sell me. They were like, "This one is a hundred leones." It's like twenty dollars, like that's a lot of money. Because a teacher in Sierra Leone makes 00:36:00about one hundred dollars a month. So twenty dollars is a lot of money. I said, "I want that dusty one over there." Not the shining ones, because that looks pretty legit to me. They were like, oh, really? Why would you want that? Because it was really dusty, covered with spider webs. I was like, "I just prefer old stuff. The new stuff looks like 'Made in China.' I want that." So this guy went up the ladder, pulled it out. It was really dusty and he tried to clean it and I said, "That looks like fifty leones." He's like, "No, a hundred leones." Well, it's twenty dollars, right, in my mind. He's like, "It's my grandmother's. I 00:37:00don't understand why you want something that my grandmother used to have." I was like, "I know, I'm just very unique, very special, I like old stuff." He's like, "Okay, a hundred leones." "If that's a hundred leones, I need another mask with it, to come with it." So I got this other mask. If you make those two, a hundred leones. He's like, "I lose money." Everyone says that but, you know. "I don't buy, I can just buy at other places." He's like, "Okay, I give you this mask." And the other mask that I got was a mask that boys wear when they get initiated, and it has gold plates, and you can see through the eyes. They're all wooden masks, and you have this band that goes through behind the ear part of the mask. So I got an initiation mask and probably a real [unclear] mask that the seller's 00:38:00grandmother used, it's pretty awesome, for twenty bucks. Yeah. That's when I learned about how these masks are used and when and how. It was just nice to hear from them. I verified, of course, because those sellers can tell me all the things that they want. But the one lady that I really got close with was explaining it to me and she actually sent me pictures down the road, like "This is my secret society's leader dancing." I was like, "Is that okay sending me those pictures?" "Oh, it's okay cause she's wearing the mask, you can't see her face." Oh, okay, brilliant. I like that.

So yes, I'm invested. I do want to go back. I'm trying to find ways, like I just got accepted to the Global Rapid Response Team in the hopes that I can contribute in a way, and even after I came back I continued to provide my 00:39:00experiences to people who were making materials. Like they were asking me about this body washing, and I think it was part of a question that the person who is interviewing at the airport or something like that, like, have you been at funerals? Have you ever washed a body? Or blah, blah, blah. And I had to explain to them, "They not only wash the body but they cook with the water, they put rocks into the water when they go to funeral, they sleep with the dead body. There are a lot of things going on." So I kind of shared what I knew so that whoever is probing can have a list of things that's possible in Sierra Leone. I contributed in that way. I also shared with people who are going back to Sierra Leone, what I've heard, what I think is a good way to earn trust from the 00:40:00locals, like know-hows if you will. Like, if you use this kind of story they'll love you, things like that. I don't know whether or not they used it to their advantage, but I feel like that was my way of giving back the best way possible.

Q: Can you tell me a little more about the Global Rapid Response Team and your potential role with those guys?

LEE: Yeah. I don't know. I just got selected. I think they're expecting the members to spend up to two months in anything urgent based on my skill sets and expertise. I have Ebola experience, I have MERS [Middle East respiratory syndrome] experience. Hopefully something that requires cultural sensitivity because sometimes--I think now I see more of, you have to be culturally sensitive and things like that as part of the requirement. So yeah, I'm looking 00:41:00forward to that. It's part of [the Division of] Global Health Protection in the Center for Global Health, and a lot of my friends are already part of that group as first-years and whatnot. They were really looking forward to having me, and I want to get all the trainings and just send me, send me, send me. I keep saying that, but they're like, oh, you're just an adrenaline junkie. I have to have my supervisory approval and what-have-you, but now that I'm part of this team I have a legitimate reason. [laughs] Yeah, looking forward to that.

Q: Great. This has been brilliant. Thank you so much for this.

LEE: You're welcome. Thank you for having me again.

Q: Of course!

[break]

LEE: Well, I did go to an MSF [Medecins Sans Frontieres] clinic. Did I tell you about that? I was able to see some patients--well, not see them, but I was away from them far enough. The reason I went there was because of how the 00:42:00psychosocial support was happening. At the time, MSF had employed mental health like psychosocial support, who are there to talk to the patients who are well enough to sit outside. This guy was Ebola positive, but very healthy. So he would sit there like, I'm counting my days until I become negative. And he was very, very healthy. He was the one talking to other patients who were very lethargic and ill, and they [MSF staff] were trying to have ways to have family visit them from a safe distance just to see progress. I think they were really hoping for their family to go back and say, oh, my loved one is being treated really well, so that that kind of story gets spread. Then people are more likely 00:43:00to trust that this is done. So I think MSF really did a good job trying to make that happen.

Q: Great. Thanks again.

LEE: You're welcome.

END