Dr. Tai-Ho Chen

Dr. Tai-Ho Chen

Q: This is Sam Robson on the phone with Dr. Tai-Ho Chen. Today's date is August 24th, 2018. I'm here in the audio recording booth at CDC's [United States Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia, and Dr. Chen is calling in from Kenya. I get to speak with Dr. Chen today about his role in CDC's Ebola response, West Africa, 2014 to 2016, for the archives of CDC Museum. Thank you so much for calling in, Dr. Chen, and to start off, would you mind just stating your full name and telling me what your current position is with CDC?

CHEN: Sure, thanks, Sam. My name is Tai-Ho Chen, and I'm currently serving as a medical epidemiologist for CDC's Division of Global HIV and Tuberculosis, stationed at the CDC office in Nairobi, Kenya. I'm also serving as a US Public Health Service officer.

Q: Thank you. If you were to tell someone in just two to three sentences, just a 00:01:00summary of how you contributed to the Ebola response, what would you say?

CHEN: I was tasked with being part of some of the first border health response teams that were sent from CDC to assist the ministries of health in West Africa in August of 2014, working on issues including airport and seaport biosecurity, and also later on, looking increasingly at issues of land borders.

Q: You mentioned the region of West Africa. Were you in all three of the heavily affected countries? Where did you go?

CHEN: Myself, I traveled to Liberia and was deployed three times during periods of active Ebola transmission during 2014 and 2015. We, of course, had other 00:02:00colleagues working on my team that also deployed to the other heavily affected countries--Sierra Leone and Guinea--and we also had a team that supported Nigeria as well, early in the outbreak response.

Q: Thank you. Can I take us back for a moment and ask you when and where you were born?

CHEN: Sure, I was born in 1969 in Taiwan and came to the US when I was three years old. My father was a graduate student, studying at Stanford University. He's a petroleum engineer and that sort of led us on a number of journeys through my youth.

Q: Does that mean that you moved around quite a bit when you were younger?

CHEN: We did. After he completed his PhD in Northern California, our next stop was the lovely town of Bartlesville, Oklahoma. We were there for a couple of 00:03:00years, and then we were in Southern California for a couple of years, and then at the age of ten, we made a very formative move to Aberdeen, Scotland, on the northeast coast of Scotland, where I lived for most of the next eight years of my life and finished secondary school there.

Q: Can you tell me more about that transition from the United States to Scotland and what that was like for you?

CHEN: Sure. At the age of ten, it was a very, very new experience, and I think that we kind of fell into it. My father actually had transfer orders to move us to Tripoli in Libya, and so we were waiting for our transfer to Tripoli. But around that time, the US Embassy was burned down and so I think everyone involved reconsidered that move and we ended up in Scotland instead. I attended local schools there, and I think had some very, very different experiences than 00:04:00I would have had we stayed in Bartlesville, Oklahoma. I have many, many great memories of friendships and outdoor activities from my childhood, and I recently had a chance to revisit some of those friends after a long, long gap.

Q: What kind of outdoor activities would you do?

CHEN: I was involved in orienteering, which at the time was quite popular in the UK [United Kingdom], navigating courses in forests by map and compass with a timed-race component to it. That was one of the activities I was very involved in throughout my secondary school. We traveled all over Scotland to go to orienteering competitions. I also learned to play rugby in Scotland, and so was actively involved in a rugby team for much of my time in secondary school.

Q: You mentioned that your father was going to be transferred to Libya and then, 00:05:00of course, that embassy burning down. I can see why you would skip that trip. Was he with the military or was he with a company?

CHEN: He was with an American oil company that had operations in many parts of the world. So stayed with the same company, but instead of going to Libya, we went to the UK.

Q: I've visited Scotland before but I've never gotten the chance to go to Aberdeen. What was it like back then when you were growing up in your teen years?

CHEN: I think it was a time when the oil industry was booming in Scotland, and specifically in Aberdeen, which sort of served as the main support base. There were a number of people from all over the world. It was a little more heterogeneous than I think it had been prior to the discovery of oil in the 00:06:00North Sea, and so there were a number of American families there and then there was an American school there that I did not attend. I attended local schools. But yeah, I think the area was sort of in flux and becoming increasing cosmopolitan at the time.

Q: Can you tell me about going to those local schools and maybe certain subjects that interested you?

CHEN: The school I attended for most of the time was Robert Gordon's College in Aberdeen, and it was at the time I think fairly traditional. At the time, it was a boys' school. It's since become a co-educational school and modernized quite a bit. I took a visit a couple years ago to see some of the changes. But at the time, it was quite traditional. The main building of the school itself was from 00:07:00the 1750s, and so a lot of history there, a lot of tradition within the primary school. I remember when I joined the primary school, we had to wear shorts year-round, even through the snow. That was just part of the tradition. I think I had the benefit of a lot of very, very outstanding teachers. I took a lot of the classics at the time. I studied Latin and a little bit of classical Greek, but was really interested in the sciences and had some tremendous teachers in chemistry and physics and biology, and I think really developed a love and interest for the sciences there that continued throughout my career.

Q: When you were graduating from secondary school and thinking about what to do next, what were your thoughts?

CHEN: At the time, in my mind at least, I had a pretty clear sense that I wanted 00:08:00to go to medical school and become a physician. I did apply to some of the universities in the UK, but I think I was most interested in returning to the US to study, to get an undergraduate degree that was maybe a little bit more broad based than going straight to medical school and then proceeding from there. I think one of the things that I really appreciated in my time in Scotland was developing a very global view of the world and having a chance to meet people from many different parts of the world there. I think I really saw myself working in global health and thought that medicine might be a good path to that for me.

Q: While you were living in Scotland, were you also traveling at some points, maybe with your father or otherwise?

CHEN: I think partly just by being in the United Kingdom, it was very easy to 00:09:00travel both through the UK and through Europe. We would typically be able to take family trips every year, sometimes fairly short, maybe a week at a time, to see other parts of Europe. We also were fortunate to have the opportunity to return back to Taiwan every year or couple of years or so to visit extended family that were still there. So yeah, I think we definitely had a lot of opportunities. I think one of the most profound travel experiences I had was through a travel scholarship that I received through my school in Scotland, which allowed me at the very end of my final year of secondary school to travel to New Zealand as a supernumerary on a cargo ship. I sailed from the Port of Tilbury in England to Auckland in New Zealand. It was a six-week voyage on a 00:10:00cargo ship, working alongside and assisting the crew as a supernumerary on board. For a seventeen-year-old, it was a pretty eye-opening experience, sailing with very, very worldly-wise British sailors halfway around the world.

Q: Oh, my gosh. I think I have some of the picture, but what made that the most profound trip do you think?

CHEN: You know, I think it was really fascinating to be able to work alongside the sailors who had--most of them were very experienced. I went on board actually with one new sailor who was straight out of a maritime school, and about the same age as me, seventeen, so the two of us went on board together. He, of course, had a specific job. I was in many ways in a more privileged position that I didn't and was put to work on various tasks that changed from day to day. Sometimes they were interesting tasks, sometimes they were tasks 00:11:00that other people didn't want to do. As an example, on the previous voyage from Australia, they carried forty-six race horses to England. The first couple weeks, I wandered around the decks with a bucket and shovel and basically shoveled up the residue from forty-six horses from the prior voyage. It was very interesting. I think one of the most fascinating things was being able to spend time with a lot of these experienced merchant seamen and hear about their travels and their voyages. Many of them had perhaps left school at a young age to go to sea, either through maritime academy or through other routes, but they'd really seen a lot of the world. I actually remember hearing about voyages to West Africa the first time, off Cote d'Ivoire and so on. Many of these sailors had sailed up and down that coast before, and I remember those stories 00:12:00that later took on a special resonance for me as sort of a place that at the time seemed incredibly exotic to me. When I returned many, many years later as part of the Ebola response, it brought back memories to that first mention of that part of the world for me.

Q: You went back to the United States for undergraduate. Where did you end up?

CHEN: I went to Stanford University in the San Francisco Bay Area and then worked for a year after college in the Bay Area, working with the Catholic Charities Immigration and Refugee Services, and got the chance to work with a number of very, very inspiring individuals, people who had come from many different parts of the world and were now sort of paying back to US society by helping orient new arrivals to the US and helping them learn English and get 00:13:00jobs and become productive members of society. Then after that, I went to medical school. Again, I stayed in the Bay Area and went to the University of California San Francisco for medical school.

Q: Very famous medical school, right?

CHEN: Yes.

Q: When I think of UC San Francisco, I think of HIV [human immunodeficiency virus] research.

CHEN: Certainly, certainly, yeah. It has been and still is one of the leading centers for HIV care and research in the US.

Q: Can you tell me about your time in medical school?

CHEN: Sure. I'd come through college, again, sort of survived the premedical gauntlet, but really was inspired to go to medical school--maybe take a little bit of a step back--by one of my professors at college. He had hosted some 00:14:00public health nights for college students--this was while at Stanford--where he brought in former students of his, colleagues, to talk about careers in public health. And actually, it was at one of those public health nights that I met someone who was an Epidemic Intelligence Service officer for CDC. I heard about his job and heard about the experiences he'd had working in public health around the world and having to have a bag packed so that he could grab it and go at a moment's notice, and it struck me as one of the most exciting career experiences to have. That definitely stuck in my mind as something that I might like to do in the future. I think that sort of helped push me through college and into medical school with that sense that I did want to do something in public health, and with a little more clarity, also global health. I knew I was very focused in 00:15:00primary care in medical school with that sort of goal in mind, and ended up at the end of medical school, matching in family medicine.

Q: Where did you do your residency then?

CHEN: I did my residency at the family medicine residency program at the University of Hawaii. Spent some time in the Pacific during that time, and that was one of the factors that had driven me to select that program. I got the chance to work with some wonderful, wonderful faculty members and really got some experience in the Pacific Islands working in both Fiji and the Republic of the Marshall Islands during my time in residency and learning about some of the issues affecting Pacific Island communities.

Q: You mentioned some of the faculty you got to work with as being super 00:16:00influential. Actually, looking at residency but also going back even to college and med school, were there some teachers or professors or faculty, whatever word you want to use, who really stand out to you when you look back?

CHEN: Absolutely. I would say in college, I mentioned the professor who had put on the public health nights, for us and I'm still in touch with him. It's Robert Siegel. Currently I think he holds dual appointments both in the Department of Human Biology and also at the Stanford Medical School. Actually, he's still actively teaching, and I usually get the chance to talk to his students maybe once a year about my public health experiences as a way of giving back a little bit in thanks for learning what I learned from him and from those experiences as an undergraduate. In medical school, I had a couple faculty members that 00:17:00definitely stood out. Dr. David Grimes, OB-GYN [obstetrician/gynecologist] who had been an EIS officer, and then Dr. Virginia Ernster, who taught us our epidemiology and also had been a prior EIS officer. I remember picking their minds about their experience with the Epidemic Intelligence Service and with CDC. I think the one thing that stuck in my mind then, and it's a little bit of a cliche, I think people throw it around a lot about how the Epidemic Intelligence Service two-year fellowship at CDC was the best two years of their professional lives. Something I've heard from a lot of people. That's something that definitely stuck in my mind and made me even more want to follow that path.

Q: Can I ask also, through your time in residency in Hawaii, etcetera, what did practicing primary care and practicing family medicine come to mean to you?

CHEN: I think practicing clinical medicine, and maybe especially primary care, and maybe especially family medicine, I see it is as a great privilege I think to be able to touch the lives of your patients, and in many cases their families as well, in a way to learn about their innermost concerns and their fears. It's a really, really profound privilege and it's one that I think as I've looked on my career, I very much appreciate that opportunity. I think there's often a tension for practitioners in public health in terms of finding that balance between clinical practice and public health. I think it can be very challenging, but it's something--I'm not in clinical practice now, but it's something that holds value, both for the experience and I think I'll always be very thankful to 00:19:00my patients for sharing what they've shared and giving me the opportunity to be a part of their lives in a way that's quite special.

Q: What happens after residency?

CHEN: After residency, I mentioned some of the tremendous faculty members in my residency experience. Dr. Neal Palafox, who was the chairman of the department at the time, he'd had a lot of experience working in the Marshall Islands previously and really helped grow the program's engagement with the Marshall Islands. He invited me to stay on the faculty, which I did for about seven years after I completed my residency in that same program. I had increasing opportunities to work in the Pacific Islands with many, many dedicated 00:20:00colleagues at the University of Hawaii supported by some federal programs including the HRSA [Health Resources and Services Administration] program to strengthen continuing education for healthcare workers in the US-affiliated Pacific Islands. It includes three territories as well as three independent nations the US has special treaty relationships with in the Pacific. I had a chance to do that and traveled fairly extensively throughout the Pacific, worked with a lot of local clinicians, doctors, nurses, other hospital staff throughout the region to aim to try and improve clinical care in that region. Tremendous experience for me. At the same time, having the chance to work with some of the communities in Hawaii in parts of Oahu that were maybe a little bit 00:21:00less--definitely less affluent--working in Central Oahu and with North Shore communities and so on. It was a really, really ..?..(21:25) learning experience for me.

Q: I have a couple questions coming off of that. The first is, were there some experiences, one experience or a couple experiences that stand out about training healthcare workers at that time that stay with you even now, that tell you something about what it means?

CHEN: Sure. I was very impressed and remain very impressed I think by clinicians who I think give up opportunities to have more affluent lifestyles, to work and 00:22:00serve communities in relatively resource-poor areas and some very resource-poor areas. There's a small island called Ebeye in the Marshall Islands. It's the second largest population center in the Marshall Islands and has a population of over ten thousand people living in a very, very confined space and there are community physicians there that are very, very dedicated to that community. And some of them from other parts of the world, from the Philippines, some Marshallese. I think getting the chance to work with that team and seeing them work in a setting that often didn't have running water, might not have reliable electricity, and yet do the best that could be done to serve those communities was really striking.

I think the other thing that struck me from that was that while the focus of our program was on helping clinicians learn and keep up with best practices and 00:23:00evidence-based practices, that it's hard to maintain outstanding care without corresponding systems that are in place to support that, and "systems: as basic as infrastructure for running water and electricity as an example. But I think other things in terms of medications and supply and so on, and I think having good referral mechanisms and services, that really struck me as a really important part of healthcare that maybe I hadn't given as much thought to previously.

Q: Were there ways that you were able to find to deal with some of those basic challenges like that lack of running water, that kind of thing?

CHEN: Yeah and I think maybe not me, I wasn't in the place that I was able to 00:24:00influence those, but I really respect those very capable administrators who were and did take measures. I think it's something that, as in many large emergency responses, goes beyond just the healthcare system and really involves other sectors. It's something that I've seen in a recurrent theme, the need to engage support from sectors outside of the traditional healthcare mechanisms to really impact change. And that's, again, I think something that was a clear piece that came out of my later work in the Ebola response as well.

Q: Just another one. I know that you were working mostly with clinicians, but did you ever have any experiences that even now stand out that were working with 00:25:00local, disadvantaged populations, something that stuck with you?

CHEN: In the Marshall Islands, part of the program that we worked with was with Marshallese who had been affected by radiation from nuclear testing. I had the opportunity to--I think what we were supported for was to help do cancer screening and so on in those populations, but also work to try and support a more primary care approach as maybe a more cost-effective approach to supporting health and wellbeing in not just that specific population, but also in their surrounding communities. I think we had the opportunity to travel to some more 00:26:00remote areas. I remember traveling with some of my Marshallese colleagues at the time who were physicians and nurses to a small island, Majetto, in the Kwajalein chain where a couple hundred people were living, and it was very remote. There was a little bit of electricity supplied by generators in some buildings, but that was pretty much the extent of electricity at the time. People were living a much more traditional subsistence lifestyle, fishing and being able to do some farming, harvesting coconuts and really, really a tremendous experience for me. Great chance to learn about ways that other people have lived, and I remember one of my Marshallese colleagues, Dr. Tom Jack, he had grown up on one of the outer islands and we were about the same age and he was telling me a little bit 00:27:00about how many youth in the Marshall Islands had lost some of those skills about how to live out in the islands, how to live by fishing and how to sail using traditional methods. He taught me this while teaching me how to properly husk a coconut. That's really stuck with me, as I think recognizing some of the wisdom that's out there that we don't always recognize and maybe increasingly is even being lost.

Q: Thank you so much for describing all of that. You were on the faculty you said for about seven years. What years were those?

CHEN: From 1999 through until 2006.

Q: So what happens then?

CHEN: Then I was accepted into the CDC Epidemic Intelligence Service fellowship 00:28:00program, and I got the chance to serve as the EIS officer assigned to the Pennsylvania State Department of Health in Harrisburg, Pennsylvania and so that's what I did for two years from 2006 onwards.

Q: Can you just tell me a little bit about that experience in Pennsylvania?

CHEN: It was tremendous. Again, I had the great fortune of working with some tremendous supervisors--Mària Moll, Andre Weltman--and then got the chance to learn from some very, very experienced field public health people. I remember I used to share a cubicle wall with Marshall Deasy, who had been a navy corpsman and then gone into public health in the State of Pennsylvania. He just had incredible stories but also so much wisdom. I think I learned more talking to 00:29:00him through this cubicle wall than I have from any textbook I've read. So a great, great opportunity. I remember one outbreak that one of my colleagues from headquarters was working on and it was related to Salmonella that people were getting. It was kind of a funny strain of Salmonella, and it was kind of unclear where it was coming from, and there were a lot of cases in Pennsylvania. I remember Marshall at one point, he was talking to one of the field staff that he was supervising and he made this comment that "Hey, a lot of these people have dogs." He just told the field staff, "Next time you go out to do a home visit and interview these people, why don't you scoop up some dog poop and take it back to the lab for testing?" I turned out this was an outbreak that was associated with commercially-produced dry dog food. It had gotten contaminated 00:30:00with this strain of Salmonella and people who were feeding their dogs and maybe not washing their hands afterwards very well were contracting Salmonella from dried dog food. You know, those sorts of things. He totally broke the outbreak based on this hunch and based on his experience. Again, tremendous learning.

I then had the opportunity to work with Dr. Stephen Ostroff, who joined the department as the head of the Bureau of Epidemiology after I had been in place for a few months. Of course, Dr. Ostroff, former senior CDC staffer, [I] learned a tremendous amount from him and [had] a great deal of mentoring and learning about how to approach things with a very, very strong degree of scientific rigor. It was a tremendous experience for me. As I said, it's a cliche--best two 00:31:00years of my professional life in many ways! So it was a tremendous experience working with that team in Pennsylvania as an EIS officer. I had the chance to do some work overseas as well so yeah, I had some great experiences there.

Q: What kind of work overseas did you do?

CHEN: Actually, it's funny. The overseas outbreak that I worked on turned out to have a link to my prior work at the University of Hawaii. You know, I'd been a faculty member there as I mentioned and one of the residents that had graduated the year that I left the faculty--we'd worked quite closely together--he had a strong family affiliation with communities in the Micronesian state of Yap--one of the four Federated States of Micronesia. And this doctor, Thane Hancock, had a strong dedication that he wanted, after he finished his residency, to support 00:32:00communities in Yap by working as a primary care physician there. So he gave up the chance to make a lot more money outside of residency to go and work in Yap as an American-trained family physician. So I got an email from him in 2007 about how they'd had had a strange outbreak on the island with about five hundred cases of fevers, rashes, and joint pain that occurred in a fairly small population of several thousand on that island just over the last six weeks or so. He knew I'd gone to CDC and asked me if CDC could provide any assistance, and he was speaking on behalf of the state health department in Yap. So I sent this opportunity at CDC and talked to a number of senior CDC scientists, and 00:33:00there was a sense that this might be an arboviral disease, probably spread by mosquitoes, and there was actually some suspicion that it might represent the eastward spread of chikungunya from out of the Indian Ocean, which had kind of been projected. And so there was a lot of interest in investigating this outbreak. There was also some thought that this might be an outbreak of dengue virus and some of the early tests had actually turned positive. The early rapid tests had returned positive for dengue virus among some of the people who were ill, so it was kind of uncertain what we were dealing with. The doctors on Yap thought it was not dengue. They actually had clinical experience with a large dengue outbreak two years before and they were I think very clinically astute and thought this was something different than dengue. It was kind of uncertain what it was, but the thought was it might be some mosquito-borne virus and that CDC should help support the investigation. I got the chance about a week or 00:34:00later to join another Epidemic Intelligence Service officer as sort of the two initial CDC responders to this outbreak of unknown cause in Yap Islands in Micronesia. Again, I think my involvement in that outbreak was really much by chance and linked to my prior work at the University of Hawaii and prior work in the Pacific Islands. Again, funny how life circles around sometimes. We worked on that outbreak. There was tremendous support from the national government of the Federated States of Micronesia. They sent out one of their environmental health heads, Moses Patrick, and worked with a lot of the very, very dedicated physicians on Yap Island, including Dr. Hancock. And also had support from WHO and the Institut Pasteur in New Caledonia, which sent an entomologist there to 00:35:00set up a mosquito lab. We had some other staff from CDC that came out, Ann [M.] Powers from the Division of Vector-Borne Diseases in Fort Collins, Colorado, at CDC. And it turned out actually, we learned after we'd been there for a couple weeks when the laboratory testing came back that this was actually the first documented outbreak of Zika virus. This was back in 2007 on Yap Island. At the time, we were all puzzled because we'd all had ideas of what might be causing this outbreak, including various viral illnesses. Almost as a running joke--the investigation team, we had this blackboard in the room that we had set up as our base and we said every time you enter the room, you had to write a different possibility up on this chalkboard. So we had a really long list of some fairly obscure pathogens--Ross River virus, o'nyong'nyong, as well as the common things 00:36:00that might cause this. People even put things up like rubella, and then there was a local rumor that maybe it was related to this new brand of rice that had been imported. Maybe there was a toxin in there. Really, really sort of literally off-the-wall stuff. Someone facetiously chalked in Zika at the top of that, once we knew the diagnosis, but of course it was a surprise to us all at the time. We'd never heard of Zika virus at the time.

Q: Oh my God. Obviously we're talking on the phone right now and you couldn't see my face, but it was the "oh my God" face when you said Zika. [laughs] Wow! I guess I have to ask, were there any cases of microcephaly that you guys were able to document in Micronesia at that time?

CHEN: Of course, we didn't know that there might be an association between Zika 00:37:00virus and birth defects at the time, but actually, in the initial letter that Thane Hancock sent me, there was actually a very prescient sentence and actually somewhat chilling sentence now in the context of history, where he mentioned the concerns about these fevers, rashes, and joint pains. He said something along the lines of, "Our clinicians are very worried about our pregnant women." And just sort of left that as one of the final sentences of his email. It was something that we thought about, how best to follow up. I think in the end what happened was the OB-GYN on island took it on himself to follow the histories, follow the pregnancy outcomes for these women who were pregnant during the time of the outbreak, probably from March through July of 2007. He didn't see any 00:38:00abnormalities in that group, but it's a pretty small birth cohort with the population of Yap. I think the birth cohort was somewhere between one hundred, two hundred births per year. Again, it was not seen at the time. It was definitely thought of, if not microcephaly, at least the possibility of there being teratogenic effects from this infection, but it wasn't seen in Yap at the time.

Q: That makes sense. Okay, thank you. This must have been 2006 to '08 was your EIS experience. What happens then?

CHEN: Yeah, so in 2008, I was looking for what I would do after EIS. Like I 00:39:00mentioned, I very much enjoyed my work in public health as an EIS officer and had the opportunity to actually return to Hawaii somewhat unexpectedly. I returned to Hawaii as a CDC career epidemiology field officer, and these are epidemiologist positions embedded in state and local health departments that request a CDC technical expert or epidemiologist to help support their routine day-to-day activities. So I ended up back in Honolulu, again, somewhat unexpectedly, embedded in the Hawaii State Department of Health. Actually went out with another CDC colleague at the time, Brant Goode, so there were two CDC folks that were hired to support the state Department of Health. That was also a very interesting time. I did that from 2008 through late 2009, and of course, 00:40:00that was the time when we had the 2009 H1N1 pandemic hit Hawaii, and to be able to experience that from the state health department perspective was very, very informative; learning to understand how public health is intricately tied to so many sectors of society outside of those that are traditionally thought of as the health sector. Yeah, very, very interesting time.

Q: I don't completely get what you mean. Tied to sectors outside the health sector? Sorry.

CHEN: I think at the time there was a lot of discussion about--for example, even about the vaccine that was projected to become available for the 2009 H1N1 influenza strain, and who should get that vaccine first, who should be prioritized. There was a thought that you should use the vaccine to obviously 00:41:00protect your first responders in health, but also first responders in other areas, your so-called critical infrastructure, your police and your fire departments, the people who keep the power stations and the water and the sewage flowing. Really fascinating discussions about what needs to be prioritized in a large epidemic setting where you're worried about the impact on society at large.

[break]

Q: So 2009, what happens then?

CHEN: I had missed the opportunity a little bit to work in support of the Pacific Islands, and I had the opportunity to stay in Hawaii but to join the CDC Division of Global Migration and Quarantine as the quarantine medical officer 00:42:00for the Honolulu Airport Quarantine Station, one of twenty quarantine stations in the US quarantine station/border health network. And part of the role that I was offered was to help support public health capacity development within the US-affiliated Pacific Islands. Again, the thought being that by supporting the ability to detect and respond to outbreaks beyond US shores in populations that did travel frequently to the US through Hawaii and through the Territories of Guam and American Samoa and the Northern Mariana Islands, we could help reduce the impact of outbreaks of communicable disease but also help to build up the infrastructure to better prevent disease outbreaks in the future. I jumped at 00:43:00that opportunity and took that position. That was in late 2009.

Q: Were there special concerns related to those populations and travel to and from the mainland United States of either picking up diseases or conditions from the United States or bringing them over?

CHEN: Yes, there were, and I think there's two parts. One was that in many of the Pacific Islands, they'd experienced disease outbreaks--they serve as travel hubs. There's a fair amount of travel back and forth, and I think for the US-affiliated Pacific Islands--again, we're talking three US territories where people who are born there are US citizens or US nationals and obviously can 00:44:00travel and work freely in the United States because of that. But also, the three Freely Associated States which are the Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau, they have special treaty arrangements with the US that also enable their citizens to travel to and work in the US without having to get visas or work permits. So I think there was a lot of discussion about what that meant, and I think there was a big push and there's continuing very, very strong work going on, much of it supported by CDC and other US federal agencies to improve the state of healthcare and reduce the susceptibility of populations to communicable and non-communicable diseases in the region. I think one of the other things that was of concern was that some of 00:45:00the US territories, especially Guam, were increasingly serving as regional travel hubs. There were a lot of travelers coming from parts of Asia as tourists for example to Guam. There were certainly a large number of Japanese tourists. Increasingly, there were tourists from China, and then also there was a lot of travel because of the visa waiver program by citizens of the Russian Federation to the Northern Mariana Islands, to Saipan especially but also Tinian and Rota that make up the Commonwealth of Northern Mariana Islands. I think there was also a lot of interest, and these were areas that were becoming increasing travel hubs for people from other parts of the world, and I think a lot of interest in strengthening the ability to detect potential outbreaks and to be 00:46:00able to respond to those and hopefully prevent those from spreading if they did occur.

Q: What kind of progress do you feel like you were able to make on that front?

CHEN: I think that one of the tremendous things of working in the region was the tremendous partnerships that exist. I think that the prior work that I had done actually when I was at the University of Hawaii in working with a lot of clinicians was very valuable. I had gotten to know many of the clinicians there, and some who were now in more senior leadership positions in health ministries and so on in 2009 onwards. And I think that there was definitely a strong commitment to improving systems, but I think systems improvement if we talk about it is a challenging thing. It involves multiple sectors, and so we also worked very closely with our US federal colleagues from the Department of the 00:47:00Interior, that supported a lot of the programs in the region. CDC actually has a number of programs that support populations in the region as well. Also, we worked very closely with Department of Defense, there obviously being a large DoD presence on Guam. I think there was a strong recognition across the board that Guam has specific relevance to the rest of the United States. It's a US territory, but it's way out there, the westernmost US territory in the world, and not far from China and not far from Japan, with a lot of travelers from those countries. And I think recognizing the importance of supporting public health development in the area. There has been, I think, a lot of progress. A lot of it has been of the sort of building programs, including immunization programs, which CDC has very much supported throughout the region; programs for 00:48:00surveillance of communicable and non-communicable diseases; and being able to develop the health infrastructure in such a way that those communities are able to do more and more with what they have. Again, I think there has been good progress. I think it's still certainly a work in progress. I'm very proud of the work that CDC has continued to do in that region, including in the US territories.

Q: How long were you doing that kind of work?

CHEN: I was involved in that work very extensively, again, from late 2009 00:49:00through--my engagement in that dropped off in late July of 2014 because of what was going on in West Africa. The next two years of my life were very heavily involved in the West Africa response and then later the Zika response.

Q: Let's get into that, the purpose for our call. [laughs] This has been a really brilliant background, so thank you so much, Dr. Chen, for giving that to us. So, West Africa, July 2014, things start to get really bad in Liberia specifically at first. Can you tell me how you initially got involved in that 00:50:00kind of work?

CHEN: Yeah. Of course, many of us from I think across the public health world had been following these reports coming out of West Africa, and a number of our CDC colleagues had actually, of course, been deployed there very early on, including I think as early as March 2014, maybe even earlier, to work on initial response to this outbreak in West Africa. I think a lot of people were wondering what was going to happen in the region. There was a clear sense, certainly from what was being transmitted through CDC channels as well as through the media, that the situation was worsening in terms of the number of cases and where the cases were in these three countries in West Africa.

It's interesting because I actually had orders to travel to San Antonio, Texas, 00:51:00on July 28th, to support the unaccompanied children's response. That year had seen a large surge in unaccompanied children showing up at the US southern border. It wasn't clear whether they had family members they could be reunited with, and so there was a surge of housing for these unaccompanied children--this was, again, back in 2014--who had shown up without parents or guardians or other family members. They were being housed while efforts could be made to identify people who could help take care of these children, ideally family members somewhere. There had been a number of shelters that had been expanded fairly 00:52:00rapidly to deal with this influx. I actually had orders to help support that response, and then, of course, in late July of 2014, there was the very unfortunate incident of a man who was actually a dual citizen--US and Liberian citizen--who got sick in Liberia and traveled to Nigeria with multiple stops along the way in West Africa and ended up dying of Ebola in a Nigerian hospital. Unfortunately, that resulted in a chain of events with, I think twenty cases of Ebola and eight deaths in Nigeria, [that] started another secondary outbreak in Nigeria. I think that really heightened a lot of the concerns that had been in place about disease transmission across borders and by air especially out of West Africa. My orders changed very, very quickly, and I was offered the 00:53:00opportunity to go to West Africa, to go to Liberia specifically, as part of the CDC response in support of World Health Organization, in support of the ministries of health in these countries, to help them. Initially, the main objective was to strengthen their ability to detect illness among outbound travelers and to strengthen their ability to reduce the risk of someone with Ebola flying out of the country, as it had just happened in Nigeria.

Q: Were you able to serve at all on the unaccompanied children response?

CHEN: I did not. Again, like I said, the next two years of my life were in many 00:54:00ways consumed in emergency response, and the first part of that certainly with Ebola response.

Q: When do you actually get out there to Liberia?

CHEN: It happened fairly quickly. Again, my orders changed, so instead of flying to San Antonio, Texas, the week of July 28th, I flew to Atlanta and prepared to deploy to Liberia. I was in Atlanta for several days and then got on a plane, met one of my colleagues from Division of Global Migration and Quarantine, Thomas George, in London, where our flights landed, and then took the very last British Airways flight from London into Monrovia, Liberia. We arrived on I think late evening, August 4th, so things happened pretty quickly.

Q: When you say that you spent several days in Atlanta preparing for the deployment, what did that consist of?

CHEN: A lot of it was getting briefings on Ebola. A little was pre-deployment 00:55:00briefings that later became very, very structured and systematized, but at the time, it was a much earlier point in the response and I think learning as much as we could about Ebola. Certainly there was a lot of concern about personal protection for CDC deployers at that time and what we should do, what we should not do. We were told that we should not enter Ebola clinical care units unless we had a specific task and [not] without proper preparation and so on. A lot of it was also learning about the scope of the outbreak, and for us specifically, what we knew about the transportation systems--air travel, how many airlines few in and out of the area, what the capacity was, where they were flying to--and trying to understand all the different ways that people moved from other countries in and out of the area. I mentioned the initial focus was very much on 00:56:00air travel, but there was also a lot of concern over sea travel, ships coming in and out of the region. Sort of a funny reflection back to my earlier experience as a teenager, hearing stories of cargo ships sailing up and down that coast. I think that was a lot of our initial preparation, and then learning who the partners would be, who our contacts would be at the Ministry and World Health Organization offices in-country. Like I said, we prepared three teams to leave very early for Liberia, Sierra Leone, and Guinea, and then a team later followed on to Nigeria. There were a lot of us working together, coordinating with those team members in Atlanta before we left in terms of how we would maintain communications within the region, how we would share information with one 00:57:00another and hopefully be able to put in place some best practices for helping to prevent travel by people who might be ill with Ebola.

Q: You mentioned that you were on the last British Airways flight into Monrovia, is that right?

CHEN: Yes, that was actually quite interesting. It was a flight that went from London to Senegal--Dakar in Senegal--and then landed on Monrovia in Liberia. It was a fairly large plane. It was like an A330. I think the capacity was like 270 passengers or something. Our flight was actually delayed about an hour in London's Heathrow [Airport] in terms of our departure, and we later learned it was because the entire flight crew had called out sick for that flight. So they were scrambling to get enough crew to be able to fly the plane. Again, we were 00:58:00delayed about an hour leaving. They finally were able to scramble up enough crew to staff the flight. The flight from London to Senegal was fairly full. I think the plane was probably like three-quarters or more full. Then the flight from Dakar to Monrovia was very short, probably less than an hour. It's one of these flights where you touch down, you let people off, let people on, and then you fly on and you don't get off the plane if you're going to Monrovia. I remember all the people getting off the plane and looking around, and I think there were maybe like a dozen passengers left on the plane for the leg going to Monrovia. We all just kind of looked at each other with this somewhat knowing and maybe half-humorous, half-scared look, like, what were we flying into? We spoke a 00:59:00little bit with the British Airways staff, the flight attendants and the pilots after we landed in Monrovia, hearing what their usual practices were when they landed because they needed to have rest time before they could fly on. They were actually the same crew that would staff the return flight the next day, because we landed late at night. From what we heard, the outbound flights were quite full at the time. A lot of people were looking to leave the region. We learned that they usually stayed at a small resort near the airport and they would overnight there and they would rest and fly back the next day. They slept on the plane and then flew the return flight back, and then we later heard after that flight came back, British Airways canceled their service to Liberia. That was not expected. It actually was part of a chain of flight service cancellations. 01:00:00There were numerous airlines--I think there were at least five airlines that stopped their service over the course of two weeks in early August to and from Monrovia. In fact, I was looking through one of my old notebooks and just looking through day-by-day notes, and this day it's oh, Air Côte d'Ivoire suspends service, and then Asky [Airlines] suspends service, and just day by day, it seemed like the airlines were just dropping this region from their service, I think in many cases because of Ebola concerns.

Q: I know that your focus became on making sure that people were adequately screened for leaving the country, but were you part of a lot of those conversations about the effect that those cancellations would have on the region and on potential transmission, those kinds of things?

CHEN: Yeah, we were certainly [aware] from the country perspective. The time that we were in-country, there were obviously much higher-level discussions going on at certainly the CDC level and HHS [US Department of Health and Human Services] level and with WHO headquarters. I think at the country level, we heard a little about these. We were extremely busy I think just on the ground. Certainly, for the first couple of weeks, I think we averaged twelve-to-fourteen-hour days, mostly at the airport. We weren't part of those higher-level discussions, but again, we were informed of some of those. Locally, there was tremendous concern about the impact that these flights stopping would have economically on a country that was already economically trying to claw its way back out of the ravages of a civil war from a few years ago that had 01:02:00devastated the economy. And also with regards to reducing the ability to bring in responders and response supplies with decreased capacity for air travel coming in. There was also a tremendous amount of concern over whether the shipping lines that brought maritime cargos into these West African countries would stop calling at these ports. And Liberia at the time was a country that imported much of its fuel and I think forty percent of its food, and most of that came in by sea, and so people didn't know what was going to happen. There was a lot of concern that a lot of these [maritime carrier] corporations might just decide, as many airlines were doing, to stop service that it would be more economically damaging to them to continue. So that was of concern, what would 01:03:00happen to these countries if some of those basic fundamental supplies and services stopped.

Q: Maybe we can take it from the moment that you arrive in-country. Would you mind describing your deployment from there on out?

CHEN: Sure. I think in response to the translocation of Ebola from Monrovia to Nigeria by this one passenger, Liberia had actually started to implement their own controls and they'd actually implemented both screening of inbound passengers and screening of outbound passengers. So when we came off the plane into one of these airports, Roberts International Airport in Monrovia (it's the 01:04:00major airport of two that serve Monrovia), and you'd get off the stairs, you'd get on a bus, the bus takes you the short distance to the terminal building, and we were met by a nurse wearing a surgical mask with a thermometer. The nurse took our temperature, and we had a screening form to fill out about where we'd been and the potential risks if we had any signs or symptoms. We kind of passed through, and [thought] that was our first introduction to: this is not normal for Liberia. This is something different. We've stepped into a different situation. We arrived and we're picked up. It was late at night. Transported to the hotel where the CDC staff had set up our base in country, and then the next 01:05:00day, hit the ground running, starting to meet with key Government of Liberia partners and meeting with the WHO representative in country to talk about what support we could provide and to learn from them what support they felt was needed. To start that partnership and that collaboration that ended up extending for many, many months.

Q: Who were some of those--if you remember--some of those Liberian people and WHO partners who were you meeting with?

CHEN: One of the key Liberian partners initially was a gentleman, Binyah Kesselly, and he wore dual hats, which at the time was extremely convenient for us. He was both the lead of the Liberia Airports Authority as well as for the seaports. So we got a chance to meet with him, talked a little bit about what we 01:06:00might bring to the table, what support we would be able to provide, and asking what he wanted. He was able to put us in touch with a key contact, the leadership at the airport in Monrovia--Roberts International Airport--and to let them know that we would be coming to visit. Again, things happened very quickly. He's someone who I think was very much in the response mode and moved very quickly to support our mission.

From the WHO side, they had some initial changes. We met the initial WHO representative. I'll have to double check his name for you but we also met with someone who had just arrived from WHO to support the WHO country office, Alex Gasasira. Dr. Gasasira actually ended up becoming the WHO representative for Liberia, later on in the outbreak. I think at the time, WHO was very much in a 01:07:00mobilization phase of trying to get more staff in-country to support different aspects of the response. I think there was a lot of interest and I think recognition that CDC could support the WHO role in terms of supporting this border health mission, and certainly at the airports and at the seaports, and that we now had people on the ground that could very much work in a way that was very aligned with what WHO was going to recommend going forward. I think it worked out very well. It was a time and place where I think all our objectives were very much aligned with the objectives of the Liberian government as well as with the objectives of WHO, and so I think it made our work in some ways very 01:08:00easy. It certainly smoothed the task for us to be able to provide the technical assistance that we had been asked to provide.

Q: Right and so that's what we're talking about for the most part is when you're talking about what CDC can offer them, it's technical assistance. What does that mean?

CHEN: Obviously, within the division that I was in in CDC at the time, the Division of Global Migration and Quarantine, I had mentioned that I worked at one of the twenty US Quarantine Stations. So CDC has had a lot of experience in the US system, the border health system in the US that is supported by these quarantine stations, has had a lot of experience in terms of preparing for potential disease outbreaks crossing borders in terms of there's been a lot of pandemic response planning at US airports: how would you screen people, what 01:09:00would you need to screen for in cases of various things like respiratory disease outbreaks (like a novel influenza outbreak, for example), who would you need to involve, who were the partners, what's the engagement you would have with the corresponding state and local health departments, hospitals with the other key agencies and institutions that are at airports, including immigration officers, customs officers, including the other staff that worked at the airport and then including with airline partners. We had a lot of experience with that and that was what we did in our day-to-day jobs. We're preparing the US for those sorts of responses should they become necessary. I think we really brought a lot of understanding of how transport systems work and what is a realistic way of being 01:10:00able to assess risks among travelers and to be able to communicate that and who that would need to be communicated to onwards. Also, I think we had a lot of experience (including direct personal experience [for] many of us) in terms of evaluating sick travelers. You know, someone gets off a plane coming into the US and they're sick and you don't know what they have. We would often get called to actually go and either do the evaluations ourselves, or if we weren't present at those airports, to do evaluations through partners, with the first responders or airport fire and rescue who would be the first ones on the plane to try and figure out if this was something that needed some degree of public health response either through follow-up, further testing, or even to the point of would it require identification of exposed passengers and a decision of how to follow those potentially exposed passengers if it was something of greater 01:11:00concern. So we've had a lot of experience with that within that division, and I think the division leadership had a vision I think for our division that although our activities were very much domestic, that we could bring a lot to global support and especially with WHO. I think that was sort of the vision of Dr. Marty Cetron, who is the division director and I think his close linkages to the World Health Organization headquarters on travel issues was one that really smoothed the path for us to be able to provide the expertise that we had in West Africa relatively quickly.

Q: Thank you. So you get in country, you have these meetings, talking about what CDC can help to provide. You said in those first couple of weeks, it was super hectic, very busy, twelve-to-fourteen-hour days. Can you kind of take me through 01:12:00those couple weeks and going to the airports and what you were doing, what your kind of day to day was?

CHEN: Sure. At the time--I mentioned there were two airports that served Monrovia, the capital of Liberia. One was much smaller and had actually suspended its international services because of the outbreak, so it was the Roberts International Airport, the larger of the two airports that we were focused on. Of interest, that other airport, the Spriggs Payne Airport, was actually the one that had been the origin airport for the gentleman who flew to Nigeria while sick with Ebola. But they shut down their international services, so we were able to focus on one primary airport. I remember arriving at the international airport the first day after we had gotten clearance and the 01:13:00official approval to work with their team, and we actually drove in the same car as Binyah Kesselly. He drove us there to the airport. Met with airport leadership and again, tried to determine what assistance we could provide in the context of what they were already doing, what their resources were, and also--I think which was very important at that point--what their concerns were. Because there was a tremendous amount of concern at the airport. The airport management obviously were not health staff, were not familiar with a public health response like this, and honestly, very few people in the world were at that point in time, but they had some Ministry of Health [and Social Welfare] staff (port health staff) that were assigned to the airport. They had worked with them, but had also recognized that they needed to increase their capacity to be able to do 01:14:00any sort of health screenings at the airport. The airport had been very proactive, and actually had gone out and hired eight new graduate nurses that had just come out of nursing school in Liberia to help support the screening program. I mentioned a little bit about what it was like to arrive through the airport the night before, and they were also doing the same screening for the outbound flights. They had developed a questionnaire that was being applied on both the outbound and inbound route. They had a lot of support actually in doing this. This had been in place I think for over a week before we arrived, again, in response to the Nigeria incident. There was a clear sense from the airport authorities they needed to be incredibly proactive to be able to address the threats. And part of what they were seeing, of course, was the threat of airlines withdrawing their services, which ended up happening in many cases.

There was a lot of support provided early on, even before our arrival, by [a 01:15:00private medical organization] that was contracted to provide medical services to a number of the corporations in Liberia. They had actually asked one of their medical leads, Mr. Shane Jacoby, to help train these nurses that had just arrived on scene in terms of what they should be doing. I really have to commend the role that these staff had done with very little notice, and Shane was very good in terms of providing some orientation to Ebola. It ended up being a very, very strong partnership that we had with both [the contractor] and one of their corporations that contracted them in terms of providing support for airport screening.

The airport screening and risk assessment effort required a lot of resources, some of which had to be brought from other places and some of which were mobilized in-country very quickly. They had, for example, provided some digital thermometers, some of these noncontact digital thermometers that became very, very ubiquitous throughout West Africa at the time, but also some types of personal protective equipment for the nurses, provided some training on how to use that equipment. We had a framework within which to work and support already. We weren't tasked with creating something de novo, and I think like I had mentioned before, the systems surrounding health interventions are so critical. In many ways, the systems had already been put in motion. The support from the airport authority to hire these nurses, to be able to identify other resources in-country that could support and provide things like thermometers, which they 01:17:00didn't have at the time. There was a tremendous incentive, obviously, to be able to prevent another incident happening as had just happened with translocation into Nigeria. Again, everyone's objectives were very, very much aligned. It made our work very easy. People were very, very eager to hear what support we could provide and what our guidance was.

Then I think the other great advantage of CDC is that we often send staff out in the field, but I think almost always they are tremendously supported by the staff who are working at headquarters. And we had a tremendous team working at headquarters to support this, both within the very, very busy viral special pathogens group (the Ebola and hemorrhagic fever SMEs [subject matter experts]) of course, were being pulled in multiple, multiple directions at the time, but also from teams of other CDC staff within the Division of Global Migration and 01:18:00Quarantine and people who had been mobilized for the response from other parts of CDC to support our group, as happened throughout the response, and supporting other teams as well. I think it was a very tremendous response from that perspective. There were some ideas that we had that were put into action very, very quickly.

One example, we recognized that in order to be able to assess the risk of passengers being ill and the risk for becoming ill, it requires not just one point of contact, one point of assessment, and this was often based on the experience we have in the United States where there are multiple layers at which someone who is sick during travel can be identified. We worked very closely with our partners to be able to have a line of communication so that those illnesses could be reported. It starts, just as an example from the US perspective again, 01:19:00with the airlines. We worked very closely with airlines so that their crew would know that if they have a sick passenger, there may be a requirement to report to US Public Health authorities, and then how that reporting is done through the quarantine station that has jurisdiction for a specific airport, and that in addition to making the clinical call, they have to have their responders on the ground to help take care of this person. But there's a public health component, too, if there's a concern over communicable diseases coming in from outside the country. We also worked with the airlines that were continuing service to Liberia at the time. We did many trainings for their staff about what to look for, for potential illnesses that might be consistent with Ebola, and also what to do to give them a sense of, how do you then protect yourself, how do you protect the other passengers around, and then how do you notify and who do you 01:20:00notify. To give them some tools to be able to address the problem in a way that doesn't cause panic or result in cases being missed. We worked with the airlines, we also worked very closely with the airport security teams, and we provided training similarly to their teams on how to recognize sick passengers and then what to do. We worked with the airport ancillary staff, the cleaners, the people who clean the bathrooms and might see passengers in places that other people wouldn't see if they were really sick. We worked closely with the immigration and customs officials so that they can also be another layer to be able to help detect potential problems and potential illnesses. I think there's been a lot of attention focused on one specific temperature check or a couple of specific temperature checkpoints. And certainly, we did work to implement best 01:21:00practices at those checkpoints, but there were a lot of other layers, too, to be able to help prevent another incident of someone who is ill potentially with Ebola from traveling.

Going back to the sort of support we got from headquarters, in the US, the Division of Global Migration and Quarantine had created these cards for US Customs and Border Protection officers that they can just hang on their ID [identification] card badge lanyard, and it has just four points--we call them RING [recognize, isolate, notify, give support] cards--in terms of how to respond to ill passengers, what do you look for, what do you need to recognize, how do you identify that and what do you then [do], how do you report. So we 01:22:00created something similar actually. We had the idea that something similar might be very useful for people involved in air and sea travel in the region, including all those partners that I mentioned above from the airlines through to people who were working at the airports. So we actually got these cards printed and sent from the US very, very quickly, and were able to distribute these as part of our training. Again, tremendous support from headquarters in helping us identify what the needs were, but also helping us to be able to provide the additional resources that were needed. Then we printed some pamphlets, but [the aforementioned private medical organization] had already developed some information pamphlets for travelers and so we worked with them in adapting and 01:23:00adding some additional input, like who would you contact, for the traveler, if you get sick after you leave this airport. Whom should you contact, what should you do. They were able to do a lot of the printing for us in-country. It was a very good partnership [with that contractor] and their corporate sponsors as well.

Q: I have a few questions here. Can I ask, when you're telling all of these different staff members of these various types--security and the bathroom cleaners and the customs, etcetera--what to look for, what are you telling them to look for?

CHEN: Ebola virus disease obviously is classified as a hemorrhagic fever, and so 01:24:00a lot of people initially at the time thought that you would expect people to be bleeding out of their nose or their mouth or seeing overt signs of bleeding. Certainly, that could happen, but actually a lot of the early presentations of the outbreak were more people feeling generally unwell with some gastrointestinal signs and symptoms, nausea, diarrhea especially, and just generally appearing unwell and maybe having a fever. I think it became much less specific, and we tried to break down the common presentation that someone who might be at various stages of Ebola virus disease might have. I think that raised a lot of challenges because, of course, most people who had any of those 01:25:00symptoms didn't have Ebola. But I think there was such a strong concern to prevent another translocation out of the country to a new country by someone who was acutely ill at the time that people became very, very conservative.

I think it raised a lot of important ethical questions in terms of: if we're helping to put in place a system that's going to stop people from traveling, and what is in place for those people that we've stopped from traveling to be able to get appropriate evaluation and care? Especially in a country where a lot of the healthcare system had shut down because of spread of Ebola through healthcare centers. A lot of the places where people would usually get care for things like malaria or to deliver their babies, a lot of those centers had shut 01:26:00down, which certainly caused a lot of additional complications and deaths I think at the time. That was a secondary effect of that, so I think it does raise a lot of questions and I think it's one that we really struggled with a lot. I'd say it was probably the major challenge that I had in that early phase of the Ebola response, was where would we send people that we stopped from traveling to get appropriately evaluated, and in a way that was safe, that was appropriate, that would meet some internationally recognized standard of care. I think that was a great challenge for us and we talked a lot about, should we try and contract medical staff to set up a clinic at the airport for example, and the airport was very, very averse to that. They did not want to be in the business 01:27:00at all of taking care of sick people. They did not see that as their role, and especially if there was a concern over these people maybe being infectious. They wanted those people at a different facility. At the time, the number of facilities that could handle those sorts of needs were pretty limited in Liberia. I think one of the lessons for me, a personal lesson I think that in future instances, that continues to be a critical piece that if we are going to help stop people from traveling, there needs to be something in place to appropriately evaluate and care for those people who have been stopped from traveling.

Q: What kinds of solutions were you able to eventually find? Where would you send these people?

CHEN: It was definitely an evolving conversation when we were there, and I think that one of the key breakthroughs on that was the involvement of the county 01:28:00health officials in that discussion. The county health officials for the county the airport was in, they oversaw the local healthcare facilities within that county, and I think once those discussions and those linkages were made, we ended up convening these airport health committees where we tried to bring in all the stakeholders to be able to solve some of these problems. Initially, what the airport did was they actually contracted their own ambulance service, or a private ambulance. So there were these two brand-new ambulances that were fully decked out that showed up at the airport one day. They sort of sat there as their means of transporting sick passengers to a healthcare facility at a time 01:29:00when the government ambulance services or the routine ambulance services were overtaxed because of Ebola in-country, or because of the other concerns, the secondary effects of there not being a functioning healthcare system for a while. Again, where does that connect to, what are the places that can evaluate? I think initially, there weren't really great solutions. The remaining Ebola treatment center near the airport was actually the former Samaritan's Purse Ebola treatment unit, the one that the two Americans had been evacuated from earlier in the outbreak. (I think, in perhaps early July 2018, the ones that came to Atlanta.) So Samaritan's Purse, the Ministry of Health for Liberia had taken over that facility, and it rapidly exceeded its capacity. That obviously 01:30:00wasn't a good solution for people who probably didn't have Ebola but needed to have an evaluation before they could travel. I think that evolved. There was a lot of discussion about, could you contract private facilities to do this? In the end, I think it was that engagement with the county, and at the same time the ability to stand up their healthcare system again, that solved that problem. But, again, I think it's an area that needs a lot of thought in my opinion in future such efforts.

Q: This seems like a minor question, but I'm interested. When you're talking about the ambulances that they were able to contract at the airport, where did the funding for that come from?

CHEN: That's a great question. The airport authority actually invested a lot of their own funding into supporting both the risk assessment efforts as well as all the corresponding pieces that went with it, and that became a little bit of an issue for discussion--probably a big issue for discussion actually--in terms of who was responsible for supporting this. Was it the Ministry of Health's role, was it an airport authority's role, was it a role for the donors who were supporting the response? I think there was a lot of back-and-forth, and I think the biggest piece of this was, who should pay the salaries for these eight nurses that were brought on board to work full time to be able to do passenger risk assessments and so on? I think it really did raise a lot of discussions, and I think that, again, there was good support from the US interagency part of 01:32:00the response. We worked very closely with USAID [United States Agency for International Development]. Their team there was tasked with bringing a lot of the resources from the US to support logistics and supplies and so on, and so we were able to get a supply of personal protective equipment through that mechanism. But I think that remained an important issue, who is going to provide the funding and support for this, and I think it remained an issue for a long time during the response.

Q: Do you remember how the answer eventually became that it would be in the airport authority's court to provide the funding?

CHEN: I think that again, it was engagement with the Ministry of Health. I think 01:33:00in my return trips to Liberia later in 2014 and 2015, we increasingly had more discussions with the Ministry of Health in terms of should the functions of these nurses, should they be brought within the Ministry of Health, should they now be MoH employees instead of airport employees? And what would be the need, what should be the sustained need for this sort of capacity at an airport or at a seaport? Those discussions certainly were ongoing. At that time, there was a lot of support from WHO in countries who were also working on these border health issues. Obviously, that was a critical part of the International Health Regulations as well. There were a lot more stakeholders that were able to be engaged in that discussion. I think ultimately, border health and port health really does require a very strong relationship between partners at points of 01:34:00entry, ports of entry, and the health infrastructure, the ministries of health and county and local health departments if those are active in the region. It really does require good communications and linkage, and I think the ability to be able to pick up the phone and talk to people to solve problems that may come up out of the blue.

Q: Absolutely, that makes sense. Did part of your guidance for these screeners in the airports and in the seaports have to do with how they would keep themselves safe?

CHEN: Yes. I had mentioned these RING cards that we had developed. The RING acronym is recognize, isolate, notify, give support. The first piece is being 01:35:00able to recognize someone who is ill that might have a communicable disease, in this case Ebola. Of course, that could range from a number of things, from someone looking like they're not steady on their feet as the first sign that you might see to someone throwing up or so on. The next part of that is "I," which is isolate. That's the key piece. We trained our (I say "our"--the health staff that we worked on the same team with, we very much felt like we were part of the same team as these health screeners) to always know that they could try and isolate this person sometimes just with distance. Sometimes that's the first response, to move everyone else away in a calm and controlled manner until they are able to put on whatever protective gear they feel is indicated, and to also keep their distance. Distance can be a very effective protective measure 01:36:00initially. We also had worked with them on how to use personal protective equipment. Now, personal protective equipment in Ebola is--and this is something that my own understanding really evolved a lot in the outbreak from talking to our experts at CDC who were very involved in training healthcare workers to take care of Ebola patients in West Africa--personal protective equipment can be used to protect people, but it can also sometimes be misused in a way that potentially might cause harm, especially if it puts someone in a situation that maybe they're not prepared to deal with in terms of how to appropriately use that equipment and how to appropriately manage someone who is sick while wearing 01:37:00this equipment. Then especially, how do you safely take off the equipment without contaminating yourself, and how do you dispose of the equipment appropriately? There were a lot of pieces to this that made it a much more complex endeavor than just handing someone a bunch of masks and a full body suit and saying, put these on and wear these eye goggles and wear gloves and make sure your shoes are covered sort of thing. It actually ended up being quite complex, and I think that it's an area the countries in West Africa had a lot of support in the infection control piece of it from CDC. We had a lot of CDC staff that worked in this infection control realm, so training people how to appropriate use PPE. I think that in the future, hopefully, that knowledge and 01:38:00capacity can be applied very early at various points throughout the outbreak, including in airports and seaports, the appropriate use of personal protective equipment and appropriate removal of and disposal of [PPE].

Q: Again, this seems like a minor question but the N in the RING cards, that's notify, is that correct?

CHEN: Yes, that's right.

Q: What was that system like? Who were these workers then supposed to notify?

CHEN: I think what we built for our screeners was that they would know how to initially evaluate someone who was sick at the airport. For all the other staff working at the airport, then their point of contact would be the health screener who would then notify their supervisor and make sure that someone could go and appropriately assess the passenger who was ill. The health screeners themselves, I think we also built a system that initially involved calls coming to CDC, that we would get called early on. But of course, a big part of our goal was to be able to take ourselves out of the equation by building local capacity, by being able to establish and strengthen the linkages with eventually the county health medical officers and the Ministry of Health. I think that's what things moved towards, and I think that was very, very appropriate. I think early on, though, at the time when there were so many priorities within the healthcare system--again, a lot of the health facilities had closed down--we did play a 01:40:00fairly key role there in terms of supporting and doing evaluations. I remember I was actually at the airport--like I mentioned, early on in the first two weeks, my colleague Thomas George and I, we spent most days at the airport into the evening. The flights, their peak arrival and departures were in the evening. They had some flights coming in the afternoon, they had some early morning flights. So we would usually arrange to be there from early morning to do some training with the staff, and then be there as they were evaluating passengers who were coming out, doing the risk assessments and so on. And at times, being on standby to provide some feedback to how they might improve their process. That was an ongoing process that included a number of things which we can talk 01:41:00about later. I was called to evaluate one of the first passengers they identified with a fever who was trying to fly to the United States. Again, initially, we were part of that algorithm because the other systems weren't in place, but I think we also worked very hard and as quickly as possible to try and build those linkages so that the system could stand on its own with local capacity.

Q: Can you tell me more about Thomas George and working with him and just describe him a little bit?

CHEN: Sure. Thomas--and I'm sure he'll listen to this. He is the officer in charge of the Houston quarantine station, one of the twenty US quarantine 01:42:00stations that make up the border health network in the United States. Very experienced in terms of border health, very experienced in terms of a lot of the preparedness activities that I had mentioned that are done by Division of Global Migration and Quarantine to help protect the United States, and very experienced in working with partners throughout both the federal travel infrastructure and the commercial travel industry. A great person to work with and I think we made a great team. He had skills and knowledge and approaches that complemented I think some of the pieces that I brought to the table, and I think for me, it really highlights the importance of good teamwork and having complementary 01:43:00skillsets as part of a team. Thomas and I were there together for over a month, from early August, and it was good to have someone else who could give a perspective on how things should be going and how things were going. I think especially when you're in situations of high stress and high fatigue, as we often found ourselves, it's important to have that second pair of eyes to give that reality check and some tips and some guidance for how we should be doing things and maybe how we shouldn't be doing things. I think that his experience working with airlines was crucial. We convened a standing meeting of the commercial airlines that flew into Liberia. They hadn't met for a while, but he 01:44:00was able to help set up that meeting and get the right people to the table and really establish some of the key working relationships with the airlines that continued to fly throughout the outbreak that really played a key role in terms of bringing in responders and supplies at a critical time. The two airlines that continued to fly were Brussels Airlines and Royal Air Maroc from Morocco. We worked very closely with them, Thomas especially, working with their country directors, working with their operational staff. It was great having someone who knew how airlines worked and what their needs and their priorities would be, so that we could try and align what we were doing to help meet those needs as much as possible in terms of protecting their crew, protecting their passengers, in 01:45:00terms of providing education and information for them when they needed it, being able to be there to do evaluations. Setting up a system that could do all of those things was I think very reassuring for the carriers that continued to fly.

Q: Zooming out for just a second, across those first few weeks or the first month when you were doing this initial work, what do you see changing on a zoomed out scale? How do you see the capacity there developing?

CHEN: Is your question specifically related to Liberia or West Africa?

Q: It's Liberia.

CHEN: I think the recognition that port health, the airports and seaports, was 01:46:00really a key function that the Ministry needed to support amongst their many other priorities including running their hospitals and their dispensaries and many other functions of the healthcare system. I think it really cemented that this was a role that the Ministry had to be involved with, that they had to consider what the appropriate resources might be at a major international airport, for example, but also at seaports, and to have that relationship where someone from the airport who has a concern in a time after Ebola is no longer [present]--those people should know whom they can call. The airport knows whom 01:47:00they can call at the Ministry, the Ministry knows whom they can call at the airport or the seaports.

Q: During this time, did you also even have time to be in contact with people who were making similar efforts in Sierra Leone or in Guinea?

CHEN: I think one of the benefits of having a little bit of time in Atlanta before we all launched was that we were able to coordinate how we would manage our communications between the teams in each of the three countries. I think really a tremendous group of people to work with from CDC--Jennifer Brooks, Katrin Kohl who was in Sierra Leone, Petra Illig who was in Guinea. A really, really great group. Gary [W.] Brunette, who went to Nigeria. We had initially 01:48:00very regular calls within our group and with headquarters at the same time, and then I think we realized that it was also important for us to maintain communications within the region between our teams because a lot of issues were coming up that were either common issues across many of the airports, and again, initially our focus was very much on the airports, especially for the first couple of weeks. And also there were issues that maybe had been solved at some airports that we were still struggling with in some of the other airports that 01:49:00we could then use and maybe learn as a growing body of best practices or potential options for solving problems. We communicated by email as well, but I think just sitting on the phone with those guys, even if it was for a short call where we'd touch base for twenty minutes, was very helpful, both in terms of a knowledge transfer, but also I think in terms of building the sense of team, that we were all in a very, very strange time and place that was very unusual from where we usually worked and that we were seeing and experiencing stressors that we didn't see as part of our day-to-day jobs. But to try and support one another through that, but also to find ways to tap the experience of this very, very experienced team to find solutions and ways out, including how to manage 01:50:00our own ability to continue to respond in this very stressful situation.

Q: Do you have an example of a time when someone from one of those other countries was able to share something that you were able to then use in Liberia, or the other way around when you shared something that they were able to use?

CHEN: There were so many discussions we had that it may be hard for me to pull out one specific instance. I think one of the issues was, of course, staffing, because in order to be able to do passenger risk assessments, it was clearly recognized that there needed to be dedicated staff who could be trained in this role, who could be available to be the people who were notified by others at the airport if there were concerns. I think that one of the things that was done in 01:51:00Sierra Leone where they had issues with staffing was that they actually had recruited medical students to be able to provide some of these services, and that was something that was discussed. We did not use that in Liberia. I'm not sure if that was a model that was maybe later applied elsewhere, but I remember thinking that this would be something that could be considered if there was an acute staffing shortage. That's one example, and again, maybe not perfect because it's not something we had applied in Liberia, but again, it was a creative, somewhat out-of-the-box solution that also required a lot of communication and collaboration to be able to accomplish, to work with the appropriate Ministry authorities but also the academic centers and the other stakeholders in that. I think that may remain a potential solution for places 01:52:00where staffing, especially in acute settings, may be limited.

Q: I think that's an excellent example, thanks. We've been talking primarily about the airports because that was your focus during the first couple weeks, as you said. When you were able to switch focus to the seaports, were there any unique issues there that were interesting?

CHEN: As I mentioned, there were a lot of concerns [about] the maritime shipping that was so crucial to the continued functioning of these countries (food and fuel were two key essentials coming in by sea) that that would shut down. The seaports had also tried to be very proactive, and I think they did a very good job. Even before we were able to get out there, they had identified areas where 01:53:00people who were sick might be evaluated safely away from others, and they also took, in my mind, a very, very enlightened approach to limiting risk at the seaports. What they did at the seaports in Liberia was they actually considered which of their staff were essential to the continued functioning of the seaport, and they certainly took a lot of measures to help protect those staff in terms of education. One of the things they did was they told them if they were sick at all, that they should not come into work if they were sick, if there was any concern they had any illness. And that they would receive their full pay while they were out sick, and that they should stay home for a period of time while receiving full pay. There wasn't an incentive for people who were sick to hide 01:54:00their illness because they needed the paycheck. I thought that was very enlightened, and that was something they had done very early on and it was very proactive. I think that probably provided a lot of reassurance to their coworkers, as well as to the Maritime Shipping Authority. One of the other things they did [changed] was that they used to have the ability to transfer crews--[cargo ship] crews could come off cargo ships previously in Liberia and fly out of the country and they could bring new crews in, so they stopped that. Any crews on the ships, they would basically stay on their ships. They would not receive shore passes, they couldn't go ashore. For the few days that these ships were loading and unloading, their crew would stay on board. So they really tried to minimize the potential contacts between the staff on the ground and the staff 01:55:00on the ships. I thought that worked pretty well. There were some people who obviously had to go aboard for inspections and so on, and I think we were able to support them in doing some work in terms of what the appropriate protective equipment might be but also what to recognize, what to look out for as potential danger signs and how to stay away from those situations if there was someone who was sick on board. Because of course, there was also the concern that these ships may have stopped in one of the other heavily affected countries before coming to Liberia. It was kind of a mutual concern on both sides of that, and I thought that the seaports did a very, very good job. They did ask us to help review a guidance statement that they were going to put out, and again, we had great support from CDC headquarters, from our staff who had a lot of experience working with the maritime industry through the US border health system. We were 01:56:00able to provide some revisions and guidance to them, so they were able to put out a maritime notice that went out to all shippers about what the restrictions were and what they were doing to help protect all of those people involved on maritime commerce on both sides of the gangplank.

Q: You've mentioned your concern about the fact that so much economic activity was taking place with trade at seaports. When you look back, what do you think the effect actually was, and how do you feel like your efforts to maintain a safe and secure border might have contributed to what happened?

CHEN: We followed very closely what was happening with shipping volumes in 01:57:00Liberia, and the last analysis I had looked at suggested there was not a decrease. I think, even for a period, there was an increase in volumes of cargo being landed by sea in Liberia during the outbreak. It's one of those great questions. In public health, often it's hard to be recognized for our successes because bad things don't happen, right? So to what extent did the efforts of the maritime authorities in Liberia that we contributed to help maintain that vital lifeline? I think it's hard to say. What I can say is that there had been a lot of worries on the Liberia side that things would shut down. Things did not shut down, and we know that there was a tremendous response by the international community, in many ways led by the United States, to support WHO, support the 01:58:00Ministry of Health in responding to the Liberia Ebola outbreak and the West African Ebola outbreak through building Ebola treatment units. There was a large influx of staff that came in to staff those from NGOs [nongovernmental organizations] from around the world. There was a huge capacity that was built up locally of healthcare workers who were trained and working in Ebola treatment units, some of whom were Ebola survivors themselves. All these efforts I think required a large amount of resources. To be able to build these centers, to bring in the supplies, to staff things, and at the same time, of course, feed the population, the fuel--to enable the country to continue functioning and avoid civic breakdown. All these things continued. It's hard to say what role we played, but I do feel that if this hadn't been addressed by the Liberia maritime 01:59:00authorities, a lot of those things might have really been much more difficult.

Q: I'm aware that we're about at the two-hour mark, and so I want to make sure that you're still okay to talk for just a little bit longer. Is that okay?

CHEN: Yeah, sure.

Q: Thank you, Dr. Chen. Is there anything remaining to say about that first deployment to Liberia, and also, what was the span of that deployment again? Was it late July to when?

CHEN: It was early August. I think we arrived August 4th. I think I left September 5th, so it was about a month for that first deployment.

I thought a lot about this, and there are a couple of people I definitely want to recognize as in many ways unsung heroes of the Ebola response in Liberia, and 02:00:00these were two people who worked at the Roberts International Airport in Liberia. One was Robert Morris. He was the deputy director for airport operations at the time. The other is Regina Benson, who was the human resources director at the airport. Both of these people had actually had prior careers working in airport settings in the United States. As you probably know, there are a lot of strong linkages between Liberia and the United States. They had spent years working in the United States for airlines and for major airports in the US, so they had a tremendous amount of experience. But they were also the sort of people who potentially could have had a foot on both sides of the border and could have left Liberia at this time of crisis to go to the United States, 02:01:00and had that opportunity. And they chose not to take it, and they chose to stay and to support the response and support their country. It's always inspiring to me because I think, at the time in the response when so many structures and institutions were at risk of breaking down in Liberia, I think the functioning of the airport and the professionalism at the airport really stood out in my mind as a beacon of hope and of light in this very, very dark time: that here was a Liberian institution that continued to function despite challenges, despite the concerns, despite the threats that they were facing and continued to function and operate and be able to provide this vital lifeline into the country that then eventually let much of the rest of the world come and help them turn 02:02:00back the tide. I think that, to me, is one of the most inspiring pieces of my time in Liberia, recognizing people like Robert and Regina. I saw that in the field of port health--and I know that there were many, many people like them working in many other sectors in Liberia who really stood there and held the line against this scourge that could have become a major scourge that would have affected the world maybe even still to this day; and because of their work, I think the world really should give a great deal of credit to those people.

Q: Do you have any specific memories of Robert Morris or Regina Benson that 02:03:00stand out to you when you look back?

CHEN: Oh gosh, we worked so closely with them for so many weeks. Regina, she was the one who managed the hiring and staffing of these nurses, the new nurses who had been hired by the airport to do the risk assessments of passengers. I remember she was in every single training that we did, even though her role was the HR [human resources] manager. She wanted to know. She wanted to know what they were being taught so that she could be a resource to them, and this was in the midst of so many other things going on--she ran HR for the entire airport. There would be times--there was a situation where an airport employee had gotten sick, and there were a lot of worries: could this person have had Ebola, could they have had contact with other employees in the airport while they were sick? 02:04:00She managed all these things so capably, but still made it a priority to be a part of the risk assessment training because she thought it was an important role for her to be able to support her staff in what they were doing.

For Robert, I think that there were just so many instances where he was dealing with crisis after crisis. I remember there was a medevac of a Spanish priest where the Spanish Air Force flew in an aircraft. They flew in a large aircraft, I think it was like an A300 or something, to medevac the Spanish priest who was sick with Ebola. I remember being there, standing in the rain with Robert as we were watching this process go through, and helping to discuss, what can we do to 02:05:00help make sure that the airport is not at risk from this medevac process that's going on with someone who ended up having Ebola (and unfortunately dying of Ebola in Spain)? I think just standing there in the rain alongside and just being able to talk about what sorts of things they could do and recognizing the vast array of responsibilities. Running airport operations, which is already I'm sure a very stressful job, and then having this very, very, potentially crushing outbreak affect that. I was just impressed that he was able to maintain all the key operations going on at the airport that needed to be kept going and did. Again, I think the airport at that time and place was a beacon of light and hope.

Q: Thank you so much for describing them a little more. You said that you had a few other deployments, too, right? Did you say two or three other deployments to Liberia?

CHEN: Yeah, to Liberia. I went back late November 2014. Spent Christmas and New Year's in Liberia with the team that was providing support there and again, at that visit, we worked with the airports, continued to look at the quality issues. Some of the things that we looked at for example, and I had mentioned briefly applying the feedback on how they could improve the quality. We looked at the record of the temperatures that were being taken at the airport, and there had been some concerns that some of the temperatures were abnormally low with the use of these thermometers. We looked at the distribution of 02:07:00temperatures and determined there were indeed some outliers, some sort of low temperatures that probably weren't realistic and that made us a little bit concerned about the quality of the temperature screening. Of course, that was just one piece of the risk assessment that had multiple layers that I described before. But what we were able to do was to work with the team and come up with a standard operating procedure to improve the accuracy of the temperature readings; and we validated that with measurements compared to other thermometers and then were able to follow the data and saw that the distribution of temperatures that were being measured was certainly much more in line with what one would expect from mass temperature screenings. We had ongoing activities like that to support the airport.

We also did have increasing work with the seaports at the time, and also at the time, even that second deployment, there was increasing discussion of what 02:08:00should be done, what could be done at these various porous land borders in the Ebola-affected countries. We were engaged with a lot of the stakeholders who were looking at what could be done and obviously, being able to stop travel across a very porous land border that had multiple places where people could cross, where people would typically cross routinely because they might live on one side and work on the other or seek care or go buy goods on the other side of the border daily. It was a very different experience and very different set of needs compared to airports and seaports, where it was a very controlled environment. There was increasing work in terms of looking at the land border issue, and of course, that work continues I'm sure today with the response to the current Ebola outbreaks in the Democratic Republic of Congo.

Q: Were you ever in conversations about potentially closing any of these 02:09:00borders, whether they were airport, seaport, or those land borders?

CHEN: Yeah, I think that was part of the discussion that was going on in the background at high levels, and sometimes in the media and other places. I think the WHO guidance at the time was that there should be controls put in place, screening assessments and so on, risk assessments, to try and maintain the necessary flow of goods and people. And again, in many cases, those goods were to support the response, to support the containment of the outbreak and the eventual ending of the outbreak, as were the people coming in. Eventually, we saw more and more support from both government agencies from many countries as well as from NGO workers from many countries. From our perspective, I think we 02:10:00were so focused on that piece to support the response that we didn't really get into those discussions very much from the ground.

Q: Did your discussion of looking at the records of temperatures and looking also at the land borders, is that stuff that you continued to do in your third deployment or were you involved in other things?

CHEN: My third deployment was interesting. This was in November of 2015. That was at the time when the outbreak had been declared over and there was not active Ebola transmission. Our thought was that this [visit] would be primarily focused on capacity building, helping to continue to strengthen the linkages 02:11:00between the Ministry of Health and the various airport/seaport authorities with the county governments and maybe looking at some of these additional land border issues. I think I was in country for a little less than thirty-six hours when our CDC team was called together with the notification that a new Ebola case had been identified in-country. I remember it was a late afternoon/early evening meeting. Of course, there was a lot of concern, and there was a lot of unknown in terms of where this case had occurred. It was just known that a case had been admitted to the John F. Kennedy Hospital, the main tertiary teaching hospital in Monrovia, that had been confirmed as having Ebola. This was a fifteen-year-old boy. We didn't know whether the boy had traveled into Monrovia or was from 02:12:00Monrovia. We didn't know what the contacts were at the time. It was just a very small piece of information that required immediate action. I remember working with the country team at that point and Des [Desmond E.] Williams, who was our CDC country director, tasked [E.] Kainne Dokubo, who was the in-country CDC epidemiologist at the time and myself to go and investigate around this case and try and find out more information. We quickly grabbed our bags that were packed. We didn't know where we were going, whether we were going up-country or into Monrovia, and we were finding information out on the fly as we prepared. A few minutes later, we were in a vehicle driving and in contact with the Ministry of Health, and found out that this boy had lived in Monrovia itself. We arrived at the site, coordinated with the Ministry of Health authorities that were already 02:13:00there at the house, and worked with them on next steps. We were actually there when the rest of the family was walked out of the house to the waiting ambulance. Again, images flashing back to the peak of the Ebola outbreak with staff who were dressed in full personal protective equipment, guiding them into the ambulance. We were walking but keeping our distance, as we had been advised to do, as part of the escort so that the rest of the family could be admitted to an Ebola treatment unit for observation. Yeah, that was a surprise. It was unexpected. A lot of the activities on my third deployment actually ended up being response activities in terms of supporting the investigation, identifying contacts who needed to be observed for their twenty-one-day observation period 02:14:00while quarantined away from other people in case they were to get sick. Unfortunately, the index patient died in that outbreak, the fifteen-year-old boy. But fortunately--I think through the tremendous efforts of the staff in Liberia who had been trained, who had been through this before--they contained that outbreak. Fortunately, it didn't extend past the immediate family.

Q: It seems cool looking back then that you got that experience in addition to all of the border focus. It's kind of like widening the different areas of the Ebola response in Liberia that you were involved in. Interesting.

CHEN: It was a very interesting piece to see and again, a chance to work with 02:15:00another great group of people from Liberia and from CDC who deployed to support that.

Q: Absolutely. I've kept you on the phone now for quite a long time. Dr. Chen, are there any questions that I should have asked, anything that I should have prompted for that you'd like to talk about?

CHEN: I just want to say a little something about the domestic risk assessment effort for Ebola that was put in place I think in October of 2014, and I had the privilege of being part of that as well. Of course, there were tremendous concerns about actually sick people traveling who might have Ebola and would be sick during their travel. Fortunately, in these West Africa outbreaks, after the 02:16:00enhanced border risk assessment pieces were put in place at the airport after the Nigeria incident, there were no further incidents of anyone acutely ill traveling out of country. There were, of course, a couple incidences of people who got sick later. They weren't sick on their outbound risk assessment but they did get sick later. Certainly, there was the case in Dallas, Texas, of someone coming from Liberia who got sick while in Dallas and there were nurses who had taken care of him who were infected. Of course, tremendous concern about what should come out of that and I think one of the pieces that came out of that was really enhancing the US response in a way that became a very collaborative and 02:17:00combined response between the US federal government and state and county health authorities. This involved standing up a risk assessment process at selected US airports where all travelers from West Africa, from these heavily affected countries, would be funneled into one of these five US domestic airports where there would be an enhanced risk assessment procedure that included temperature monitoring, that included evaluation for illness. Again, in many ways parallel to some of the pieces that we had helped strengthen in West Africa. I think many of us had experience in West Africa at that point. I was part of the team that helped support the setup of this with our US Customs and Border Protection colleagues at Dulles International Airport in Washington, DC. I did that for 02:18:00about a month, starting in mid-October or so of 2014. It was kind of an interesting other piece of it. I think one of the things that I learned from that was the importance of having a strong state and local health department system like we do in the United States, because the risk assessment that we did at the airports was part of it but there was also a secondary piece which related to monitoring people for signs of illness (people who had been in the Ebola-affected countries, monitoring for signs of illness), and that degree of monitoring would depend on the risk of what they had been doing in Liberia [or another affected country]. People who had been working in Ebola treatment units for example would receive a higher level of monitoring. CDC developed the guidance for this, but I think it couldn't have happened without the strong work and participation and collaboration with US state and local health authorities 02:19:00who took on the huge burden of following these thousands and thousands of people coming back, some of whom were responders, some of whom were just people who would have traveled anyway from these countries, and I think really stepped up to the plate in this huge effort. Again, I think just to recognize the critical importance of state and local public health in the United States. Again, this is just one small piece out of the many, many functions that they do sometimes invisibly to the average American but that really help protect our nation, protect our states and our counties, and protect our communities.

One last thing, just kind of a personal anecdote on this. While I was at Dulles, I was called to evaluate someone who had returned from Liberia, and he was a doctor who had worked in an Ebola treatment unit in Monrovia. The flight through 02:20:00West Africa to the US, there were no direct flights at the time, so people had to fly though somewhere else like Brussels. By the time they got to a US point of entry, they had often been traveling, including time spent getting to the airport and waiting and so on, for twenty-plus hours or so. People were generally pretty exhausted at this point, and they're having to often wait to be evaluated. I remember going in, and there had been frustrations on both ends I think. Sometimes people missed their flights because they had to wait for this enhanced risk assessment, and I think there had been some frustrations. This doctor had expressed some frustrations to our customs and border protection colleagues who were an integral part of this process in helping to control the flow of people and being able to help support the enhanced risk assessment. I 02:21:00remember just sort of sensing that frustration. It struck me that here's someone--that this could have been me coming back from the response. We were working in different roles, but I think we were all part of the same team, trying to turn back the tide of this outbreak with our Liberian colleagues. I thanked him. I said, "Thank you for what you're doing." I think that a lot of times, we probably don't thank those people enough. Again, just to leave that as a closing note.

Q: How did he respond?

CHEN: He was grateful, and he mentioned actually it was the first thanks he had gotten for the role he played in responding to the outbreak.

Q: Actually, that brings up another good question. What kinds of feedback did you receive from the Liberians across your deployments on the kinds of guidance 02:22:00that you were able to give?

CHEN: I think that we were warmly received. Certainly, coming back to Liberia a second time, I knew and was known by many of the people we worked with, certainly at the airport, and I think that we were welcomed back. I think we were welcomed back because we had helped provide support at a time when they very much appreciated that support. It was a time I guess at the early stage of what ended up being a very, very large international response, and I think successful international response. It was good to see them again, and I think it rapidly helped us evolve our relationship from beyond just colleagues, I think in many cases, to friends. I think that's something that will always be important to me, those friendships that developed in the midst of a very, very 02:23:00challenging time.

Q: Thank you so much for talking with me from Kenya, Dr. Tai-Ho Chen. It's been a privilege to hear about your work on these multiple, three deployments, and also just your personal history. Thank you for your time.

CHEN: Thanks very much for the opportunity, Sam.

Q: Of course.

END