Trunos Grison

Trunos Grison

Q: This is Sam Robson. It is March 14th, 2017, and I'm here at the emergency operations center, EOC, of Monrovia, Liberia, interviewing Mr. Trunos Grison about his experiences as part of responding to Ebola in Liberia. This is part of the CDC [Centers for Disease Control and Prevention] Ebola Response Oral History Project conducted by the David J. Sencer CDC Museum in Atlanta. Mr. Grison, thank you so much for being here. I appreciate your time and I look forward to hearing about your experiences.

GRISON: Thank you for having me.

Q: Of course. Would you mind first just saying, "My name is," and then pronounce your full name?

GRISON: My name is Trunos Grison. I am from Zimbabwe.

Q: Where were you born in Zimbabwe?

GRISON: In Zimbabwe I was born in a place called Zvishavane. It's a town which 00:01:00is in the Midlands Province, the midlands part of Zimbabwe.

Q: When were you born?

GRISON: I was born in 1975, October, October the 12th.

Q: If you were to tell someone in just a couple of sentences what your role in the Ebola response was, what would you say?

GRISON: My role in the Ebola response is basically I came here under Riders for Health. The main role that I played as an individual under the organization was to set up the sample transport system, which was meant to respond to Ebola 00:02:00samples from wherever they were going to be generated. By that time, generally most of the health facilities were closed. Only the major places, only the major referral hospitals, which were at the county level and some of the district-level hospitals, were operational. There were also ETUs [Ebola treatment units] and the CCCs, which were what they used to call the triple Cs, the community care centers where they would actually put in people who were suspected to be having Ebola or those who are already known to be having Ebola, where they would keep them and then transfer them to the ETUs for the treatment 00:03:00of Ebola. My main role, when I came here, was first to have an assessment of where can we actually start from, in terms of setting up the sample transport system that would take care of all those samples, which needed to be referred to the laboratories for testing.

Q: Can I back us up for just a second, so that I make sure that we get our--

GRISON: All that, yeah, sure.

Q: Great, thank you. What was it like growing up in Zimbabwe?

GRISON: Like any other ordinary boy as a Zimbabwean, I grew up, initially I was from the rural areas of Chivi, where I grew up. I did my first grade there, 00:04:00second grade, and third grade. Then we moved the family, as a family we moved over to Harare, where I completed my primary school and also my secondary school. Then I did my high school. After that, I looked for work. In '95 the economic situation was not really good, so I got a job--actually, I got a place as an apprentice in motorcycle mechanics. It's a course that takes about four years to complete. I did my apprenticeship, completed it in 1999, that was from 00:05:00'95 to 1999 with Yamaha Center, Yamaha Center in Zimbabwe. After completing my four years of apprenticeship, I then joined Riders for Health in 2002, where I was an outreach maintenance technician, taking care and maintaining about sixty motorcycles in a particular region, which was Mashonaland Central. Zimbabwe is divided into some political provinces. My province which I was assigned to was Mashonaland East, where I would go out on a monthly basis to take care of the 00:06:00motorcycles for the environmental health workers doing all the preventative maintenance on the motorcycles. Basically, this is how I started my journey, as someone who would end up in a health-related setup working with colleagues in the health delivery system. This is how I really started. That's how my professional career actually began in Zimbabwe.

As an aspiring young person, I also decided to not only just remain a mechanic, or a motorcycle technician. I decided to work on improving myself. With the 00:07:00trust that the organization had in me, I started moving up the ranks. I became the head of the workshop in Harare for all the motorcycle technicians, who would actually report to me and then I'll produce some reports. I was supervising all the motorcycle technicians in Zimbabwe during that time. From there, I was moved to another province, Midlands Province. I became the provincial manager, taking 00:08:00care of both motorcycles and motor vehicles in that province. So I was heading the province, looking after the motor vehicles for the Ministry of Health [and Child Welfare] and motorcycles for the Ministry of Health.

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Q: Okay, so you were in charge of the province?

GRISON: Yes, I was in charge of the province. That was in 2007--part of 2007 and up to 2009, before I was recalled back to Harare, the main unit, where I became the technical manager. I became the technical manager of the program, managing the entire fleet, supervising all the technical personnel of the organization.

Then in 2010, we got engaged in a sample transport project, which was funded by 00:09:00USAID, but it was implemented by The [International] Union Against Tuberculosis and Lung Disease, called The Union. This was our first sample transport project in Zimbabwe. Of course, we already had a sample transport project which was running in Lesotho by then. I once went to Lesotho. There, I actually did set up the first workshop in Lesotho when I was still the technical manager. But talking about the first project of sample transport in Zimbabwe, which we did 00:10:00set up with The Union in 2010. I spearheaded that first set-up, which involved a pilot for three motorbikes, and then we added another four motorbikes, which were essentially looking at--their first target was actually the councils, like Harare City Council, and then Chitungwiza City Council and then Bulawayo City Council. Those were their main focal areas. They were looking at TB [tuberculosis], making sure that all TB cases are arrested, those with TB are diagnosed and they are given the proper intervention or treatment after their samples have been tested. We managed to pilot the project well. By then now I 00:11:00had moved from being--I had changed my position from being a technical manager to a sample transport manager. I wanted to be, I was going to be full-time on the sample transport system, make sure I designed all the necessary tools that need to be implemented to make sure that we really piloted properly. We did everything right, and also that made us expand in 2012 and 2013 to include about five rural area districts in 2012. Then in 2013, we further expanded the system with thirty-two motorcycles. The Union got additional funding to expand the 00:12:00project, so thirty-two more motorcycles were included into this, in the system, and that was really good.

It was a very successful project--it's still running up to now. About forty-nine motorcycles ended up being in the system. Also, some other organizations decided to engage Riders for Health to help them with some sample transport systems. We were engaged with MSF [Médecins Sans Frontières] to actually transport 00:13:00specimens in a district called Buhera, Buhera District. Buhera is divided into the south and the north, and we were using two couriers who would collect samples across the two areas, Buhera North and Buhera South. MSF was concentrating on HIV [human immunodeficiency virus] viral load, and The Union was concentrating on TB here, but also, TB is correlated to HIV. What makes sense was that as we collect the TB samples, we also collect the other samples, which are related, which are like HIV samples, the dried blood specimens, dried blood spots. We also carried them along as we transported the TB samples.

And also CHAI [Clinton Health Access Initiative], CHAI also came into the picture--that was in 2012. We actually had two projects with CHAI. The first one was in 2011 whereby we were transporting some dried blood spots for early infant diagnosis, trying to screen for HIV in the young, in the children. We were using five motorcycles in a place called Matabeleland, Matabeleland Province. That was in Bulawayo--we were using one of the labs [laboratories] there called Mpilo Lab 00:15:00in Bulawayo. We were collecting specimens from five sites for those EIDs [identifications]. It was also a success, and the projects were later taken over by ZINQAP. ZINQAP is like a board which looks at the lab systems in Zimbabwe. When CHAI funds ran out, then ZINQAP took over, but later on, around 2012, there was no more funding for that project and some of the couriers we actually transitioned on to The Union project for TB samples.

Then with CHAI, we did run another sample transport project, which was sort of a 00:16:00hybrid system whereby we used non-dedicated couriers and dedicated couriers. [In] the system we were running all along with The Union, we were using what you call "dedicated couriers." Dedicated couriers are couriers employed specifically to carry samples every day, which is the same system that we are using here in Liberia. Someone just wakes up, takes the motorcycles, carries the plans, and prepares to go for sample transportation, etcetera, etcetera. The last project we did with CHAI in Zimbabwe, it was an integrated system whereby we used two 00:17:00different sets of employees. We were using the EHTs [environmental health technicians] to carry the samples. Riders was only maintaining the motorcycles for the EHTs, collecting data from the EHTs, but the people who were doing the actual transportation of the samples, it was the Ministry of Health employees, who are what they term the "environmental health technicians." It was sort of a 00:18:00mixed system whereby three partners were involved in the system. One, which was CHAI, was funding the project. Riders doing the logistics, taking care of the motorcycles, ensuring that motorcycles are running properly, giving out the logistical supplies like the fuels. Of course, the funds were flowing through Riders for Health to the EHTs, who were doing the work on the ground. That was the last project we did with CHAI. So yeah, that was the last project we implemented with CHAI.

Q: Also, what does CHAI stand for?

GRISON: CHAI is the Clinton Health Access Initiative. It's one of the American organizations.

Those are the major projects that we had in Zimbabwe for sample transport. 00:19:00Currently, the one which is running now is the one which we are having with The Union, which is also funded by USAID. We have an ongoing, renewable, five-year contract. So it's going on well, using motorcycles.

Moving ahead, as I continue working with Riders for Health, in 2015--okay, after 00:20:00we had completely set up The Union sample transport system and also going through the other contracts we had with various organizations, I finally became the operations manager for Riders for Health. That was in 2012. I became the operations manager for Riders for Health, and we continued as that set up until there were no major, any other major set-ups--but of course, they are here and there. Some other projects which came in, which were really not sample transport related--we also do what is called "fleet management" for the Ministry of Health 00:21:00and other partners. But with sample transport, finally, in 2015, this is the year when we came to Liberia as part of the Ebola response team. To be specific, that was February, in February 2015. We came here under CDC--by then it was CDC Foundation who provided the first funds to kick off the setting up of the sample transport system.

Q: So then was it CDC who invited you originally to come to Liberia?

GRISON: Yes, that was CDC. Of course, the Ministry of Health [and Social Welfare] was involved. Earlier on, negotiations were in the pipeline with the 00:22:00Ministry of Health and our UK [United Kingdom] office to come to Liberia to set up their fleet management system. But then, this opportunity to come became so clear when Ebola hit Liberia. Riders for Health really got the opportunity to expeditiously set up the system. Instead of setting up with the fleet management, it was the sample transport system that came here. That had to be set up first. It was a priority because there was the real need for us to make sure that we set up a system, a functional system that would carry specimens 00:23:00from every part of the country to the laboratories for testing. This system, this was really based on my experience from Zimbabwe, and also of course, my experience in other countries like Lesotho. Lesotho was already running a sample transport system by then. This one started around 2008, so in 2008 I also went to Lesotho just to set up their first workshop.

Q: You went to Lesotho to help them set up their--

GRISON: Set up their first motorcycle workshop. That's when they started running the sample transport system, in 2008. This is where I really got my first contacts to know what is sample transport. When I came back to Zimbabwe, it was 00:24:00really easy to know where to start from and start building up the knowledge from there, until I got the experience of setting up all the other sample transport systems in Zimbabwe.

The opportunity to come to Liberia--of course, I had visited other countries like Kenya. I set up their first motorcycle workshop there in a place called Kisumu. It was one of my experiences there, but it was only for fleet management purposes with different organizations like Vhumilia and then other NGOs 00:25:00[nongovernmental organizations] there who were humanitarian organizations working with children, orphans. It was just basically fleet management, and there was no sample transport system involved. Of course, I've also visited like--I've worked in Madagascar, for instance, where we went there for--it was a consultancy whereby we worked with PIVOT. PIVOT, they had some health workers who they needed to work with motorcycles. They needed the drivers for the health workers. We trained the drivers who were going to carry the health workers on 00:26:00the motorcycles. It was one of those good experiences. It was my first time in Madagascar, and there was also the issue of the language. I didn't--they speak Malagasy and French. But the training was very good, it was one of the most successful trainings that we have ever held. Training through an interpreter, giving instructions. There were two of us from Riders for Health, we came down to train these riders and the health workers too, we trained them just in case the driver has a problem, the health worker can also pick up the motorcycles and ride.

Q: Were there ever times in Liberia where motorcyclists transported people instead of specimens?

GRISON: In Liberia, no. It was purely, it's purely specimens, yeah. But in Madagascar it was a very different situation, very different scenario. We managed to train about twenty-two people there. And of course, from my experience with working on the motorcycle itself, I can repair the motorcycle, I can train people how to ride. This combined with my knowledge of sample transport and the basic IPC [infection prevention and control] knowledge on what 00:28:00someone should do and not do when transporting specimens, all of that gave me the overall skills that I need to set up the system. Together with my managerial skills that I've built over time, from being a workshop head to an operations manager, and at one point I was also a marketing manager. That was in 2006, that was before I went to Midlands. I was a marketing manager for the organization, marketing the different packages that Riders for Health was offering.

But anyway, a sample transport system was a very difficult thing to resist because there was really the need for a sample transport system in Liberia to 00:29:00transport the Ebola samples. Because there was no systematic approach to the transportation of these specimens across the country. Also, it was so expensive to transport specimens. More so when it's not systematic, it becomes very expensive because one will be forced to carry a sample, one sample from the far end or the far corner of the country coming to a lab in Monrovia. That would definitely be very expensive, and infrastructure here is a bit of a challenge in terms of laboratories. By the time we started the set-up, there were, I can 00:30:00still remember there were seven labs working. Again, count--LIBR [Liberian Institute for Biomedical Research] lab, ELWA [Eternal Love Winning Africa] lab. We had MSF lab in Monrovia, which was testing. We had Sinje in Grand Cape Mount [County], we had Tappita in the Far East there. I think we had another lab [Bong Phebe Lab] somewhere. Then the others were generally mobile labs, which were set during the time of Ebola. All of the lab units were close to nine or so, which was set up for the Ebola response. But eventually, as time goes on, as the level 00:31:00of instances began to drop, all the other mobile labs began to fold, and they actually ceased operations. Now we are left with only four labs, of which the other lab, ELWA, is now being earmarked for closing. We will essentially remain with three labs. Logistically, it's very difficult if the system is not as systematic to make sure that samples really move from the peripheral [health units] to the laboratories, and also the labs are skewed towards Monrovia. All 00:32:00the samples from the southeast have to move towards Monrovia way. There's one lab in the central part, in Nimba [County], but still it's closer, it's coming towards closer to Monrovia. That is one challenge, the issue of infrastructure in terms of laboratories.

Then the nature of the terrain in Liberia, it's a very difficult terrain. Some areas actually get cut off, they become impassable for two weeks or so. Someone can be made to stay at a certain place for two weeks, one week--

Q: What kind of thing would cause that?

GRISON: The mud, you cannot pass. Liberia is full of forests and there's only one way to pass. The road can actually get blocked by vehicles which have failed to pass a certain part. All the cars queue up until they bring up a construction vehicle, one that can actually pull out the one vehicle by vehicle, pulling them out and straighten up the road for them to pass. So the terrain is a very big challenge here.

Coming back to the setting up process, we go through a certain kind of process 00:34:00when we do the set-up of sample transport. First of all, we do what is called the feasibility assessment whereby we go to the county health teams, for instance, here in Liberia there are county health teams, which they call the CHTs. Obviously, the first step is to get the concurrence from the national level, from the central Ministry. Once all that concurrence is obtained, all necessary contracts, all necessary paperwork is done, then we go to the county health teams, do our feasibility assessment, which involves talking to the 00:35:00county health teams. We try to find out--make a needs assessment, have meetings. They come up with suggestions, they tell you where the most need is, they tell you the geographical arrangements of the facilities in their area. They tell you the geographical locations of the laboratories. Then from there, you try to map up a feasible route around that cluster of clinics. It might involve you probably dividing the cluster of clinics into two or three clusters, and then 00:36:00you can actually design your routing system from that kind of information. But obviously, the first thing is to get the need, to make the needs assessment, and you can now map up from there. For ours, the focus was on the Ebola specimens, which basically needed to be moved from the ETUs, triple Cs, district-level hospitals, and other county-level hospitals, to the laboratories. Because during that time, most of the other, smaller health facilities were closed, so we designed our routes along the county-to-county movements.

After having done this route assessment, the feasibility assessment, we come up with some action points. What do we need to do? Okay, we need to hire some couriers. We need how many bikes? We need to train these couriers. How do we recruit the couriers? We also need assistance from the county health teams themselves. They will do their own recommendation. In our case, we had to hire what they call the gCHVs. The gCHVs are general community health volunteers. 00:38:00Those were the people who were giving information on health-related issues. When there is Ebola, someone suspected of Ebola, they would actually give information to the health facilities, transport information. Those were the people that we targeted. Then we asked the county health teams to advertise for the sample transport position, earmarking the gCHVs. Then we did the recruitment process.

Initially, we set up something like sixty-six gCHVs that we employed, and we set 00:39:00them up in sixty-six strategic bases. Because by nature it was so difficult for one person to carry a sample from the very end to come all the way to, say, Monrovia, which is about seven hundred kilometers, we had to design the system in such a way that there will be a pass-on system of the samples from one courier to the other until it goes to a respective lab. This had, obviously, the 00:40:00advantage that the courier doesn't have to strain all the way to the lab, and then the motorcycle life is also conserved. But what we really wanted to establish is the standard operation procedure. How do they do their relay? How do they pass on the samples from one courier to the other? How do they make sure that the next courier is ready for the relay of the samples? Speed is of the essence here. The turnaround time is always very critical when you're dealing with samples. You have to make sure that you take the sample in the shortest possible time to the laboratory. It has got a bearing on the quality of the sample and also on the quality of the results. We needed to develop that 00:41:00standard operating procedure, which we developed over time.

After employing the couriers, we finally trained them, we trained them. We trained them on how to ride the motorcycles, we trained them on how to do the IPC, the [infection prevention and control], when they are handling the specimen. How to handle the specimen, the do's and don'ts so that they don't infect themselves or infect others. That is the biosafety rules and prevention control. We told them those are the major areas that they need to be taught on. 00:42:00How to ride the motorcycle properly in any environment, the off-road and on-road, and then the IPC. We managed to do all that, and of course, we needed to equip them with the necessary equipment for the samples and also keep them, in terms of the riding gear. Liberia is very hot, humid. Those are some of the challenges that we actually faced. The riding gear that we use, that we were used to actually, it was for very cold climates. When it's very hot, it has got a thermal lining, which will actually make you feel warm on the motorcycle. Here, it's very humid and very hot. So we first gave out the kit that we were 00:43:00used to, and there were complaints of dehydration. We had to change over to look for something which was suitable for this climate. What we needed to do was now to look for a highly perforated suit, of course, which has got protection in some other areas but which would allow air into the body so that one becomes cooled off during riding rather than being heated up. In terms of during the rain, then we had to add on the rain suit. When it's raining, one is to put that rain suit on. It was one of those challenges that we actually faced in Liberia, 00:44:00in terms of our materials for the riders to use when they are on the motorcycle.

Oh yes, and the perfect bike was the [Yamaha] AG200. We already had experience with the AG200 in the other countries that we operated in. We procured those ones.

Q: What is so good about them?

GRISON: The AG200, it is a high-profile motorcycle. It is not a very speedy bike, but it has good, very good tractive power. It doesn't have any terrain which is difficult for it to go through, especially the mud, the hills. It's very good. It's got that capacity and potential to go over any terrain. In 00:45:00Liberia, it worked very well. It is actually the perfect bike for the system, working in Liberia. Using a motorcycle, it was much more appropriate than using a vehicle because a motorcycle doesn't need a very wide path. It just needs a very narrow path to follow. If you can just place your wheel in the right direction, then you can go through anywhere easily, unlike a car, you need to find a way to go through, I mean to navigate and stuff like that. It's very 00:46:00difficult on the vehicle. So the system was set up on that. We managed to set up the sample transport system throughout the whole country, in all of the counties to transport all the EVD [Ebola virus disease] samples. Of course, before us, there were other organizations who were transporting the samples, the Ebola samples, but they were using vehicles.

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Q: Sorry, we had a battery malfunction. I am back now with Mr. Trunos Grison. Sorry, I lost our train of thought.

GRISON: Okay, I don't know how much we have lost.

Q: Nothing.

GRISON: Nothing has been lost, so that's fine. Like I said, we managed to set up 00:47:00the sample transport system based on that, and finally, we were the sole transporter, the sample transport, especially the Ebola specimens. We finally took over, and it was really working pretty well, although there were so many other challenges that we had as we were going through our learning curve of the system. Our couriers were new to the system, but as time goes on, everybody became mature in the system and things started improving and getting better. The 00:48:00beauty about the system that we set up is that in the event that the couriers cannot pass in one direction, we can easily reverse their route into the other direction and still get the same transportation results through the same relay systems. That way it's very flexible. We can reroute samples, we can move samples in one direction and we can move it in the reverse direction depending on where the samples need to go to. We have done that especially during the heightened surveillance of the Ebola virus from August to I think December of 2015.

Q: 2015 or 2014?

GRISON: 2015.

Q: Okay.

GRISON: Yeah.

Q: There was heightened surveillance at the end of 2015?

GRISON: At the end of 2015, yes. There was heightened surveillance of the Ebola virus then. There was a huge number of samples that were being produced from the communities and from the health facilities, lower health facility level. The point was that we wanted to make sure--the Ministry and everybody else wanted to make sure that they touch every corner of the country to search for any case.

Q: Was this one of the times that Ebola recurred?

GRISON: Ebola recurred in June, I think May, May--

Q: Of 2015?

GRISON: May 2015, yeah. So it was before the heighted surveillance actually.

Q: Gotcha.

GRISON: Yeah. Multitudes of samples were being produced, and you'd find out that one lab might be overwhelmed with samples and then they had to shift the workload onto another laboratory, which it would then mean that, as Riders for Health, who were transporting samples, we had to be flexible in such a way that we changed the direction of sample delivery. We changed the route to make sure that the samples which were going, for instance, to Tappita, they have to go to 00:51:00Bong Phebe lab. Or the sample was going to Phebe lab, they have to go to LIBR, or vice-versa in all directions. This is how the system was working. This is how the system can also work, even today. It has the capacity and potential to do that.

Q: I think I might have missed something. Why was there a period of heightened surveillance from August to December of 2015?

GRISON: It was an initiative of WHO [World Health Organization] and the Ministry of Health to make sure that all the suspected cases--everybody tested whether there's any Ebola virus that can be detected from all the suspected cases, just 00:52:00to make sure the country is clean of the disease. Every dead body was going to be swabbed to make sure that the person who died is not due to Ebola. If it's Ebola, that means that there has to be a lot of contact tracing to make sure that all the contacts are tested to sort of clean up. That was after the last case was declared to be Ebola-free. That was the sense and purpose of the heightened surveillance for us, for the country to be sure now there's no--any residual Ebola cases in the system.

Q: I understand.

GRISON: We had been running the system up to now, and it's really working well, and now we have also--so after the Ebola crisis was declared over, the country now started moving to a more or less normal health delivery system. Some of the facilities which were closed, they began opening up. It also meant that Riders had more work to do carrying samples from those areas which were once closed and 00:54:00now they're opening up. And also the ETUs and the triple Cs were decommissioned once there was no more Ebola. When one is put in an ETU, there's that sense of fear that Ebola still exists, so they needed to decommission those ETUs and now the other health facilities were opening up.

Now, one challenge that faced Riders for Health is that since it was the only organization transporting specimens, the initial plan was that Riders would pick up specimens from a specific number of facilities, which was 302, in our case. 00:55:00But with the opening up of the other facilities, there was an overwhelming number that would balloon up to about five hundred and so, over five hundred facilities Riders had been picking up samples from. That had a lot of pressure on the resources in terms of the fuel, in terms of the motorcycle maintenance, and also in terms of the courier time that he spends on the motorcycle, that relative fatigue that is associated with riding a motorcycle for a long period 00:56:00of time. Of course, fatigue, you end up having more accidents, and that means that we also had more breakdowns. Of course, our budget was really not matching up, all the time, with this sudden change of operations. This is how it became a challenge. What was necessary was now to go back and discuss with the health facilities, discuss with CDC, discuss with the health facilities, tell them Riders is only picking from these 302 facilities. The Ministry needs to find 00:57:00other means to transport samples to bring them to Riders for Health pickup points, and then Riders for Health will pick them from there and then take them to the laboratory. This has been the discussion of, I think, six months, and now we're getting there. The ministries and other partners, actually, are beginning to--they've actually accepted that Riders cannot pick samples from each and every other corner of the country, but stick to the 302 facilities, given the amount of resources that are planned under the current project. So it's really 00:58:00now working, we will continue to push to make sure that everybody keeps on understanding the fact.

Q: So is that where you are now, then?

GRISON: This is where we are now. This is where we are now. Some of the cases entail us going back to the county health teams, to the county health management teams, and also to restructure the routes in the way that will include some of the facilities where they see there is more need to have the samples being picked up. But we also have some parameters that we have set. We have the golden 00:59:00rule of saying we are only picking within the fifty-kilometer radius of the sample courier's base station. Because the courier has got some assigned facilities, but he is also stationed at a particular health facility. It might also involve that process of restructuring the routes, but still sticking to the planned number of facilities. This is how it is.

One other aspect is that the way we scheduled the routes, it was scheduled in 01:00:00such a way that the courier would have a regular route on each and every day that he has to follow. It was a fixed routine system initially. But now, the samples have dropped. The new IDSR [Integrated Disease Surveillance and Response] guidelines, they have said that the health facilities should no longer randomly collect samples from each and every patient that visits the clinic, but they should also screen for other conditions because the country is now sure that Ebola is gone. Ebola is gone, so instead of anyone with fever to be--to 01:01:00have an extraction of a sample from any patient with fever, they would say that patient, can they test for malaria, treat for malaria, treat for any other conditions before they can actually extract the sample for testing for things like Ebola and so forth. Now the sample, the level of collection from the health facilities has dropped. During the Ebola and the heightened surveillance, we were collecting something like three thousand five hundred samples in a month, but now we are averaging below five hundred samples in a month. We are now operating at a very different level, a different level in terms of the numbers 01:02:00of samples that we are transporting. Instead of our couriers doing the regular routes on a fixed schedule system, whereby each morning they have to wake up and go through the rounds; now that all the facilities are no longer collecting every day, they will not pick up maybe any sample from the routes. We have decided to change the mode of pickup now to a dynamic pickup system whereby the courier will only travel to pick up the sample after he or she receives a call 01:03:00alert to say there's a sample in this facility. This is when the courier can actually go and pick up the sample. This dynamic system, it works well with a strengthened communication system whereby it is said that the courier has to call to check on the health facilities whether there is any sample. The health facility also has to call the courier to say there's a sample here, come and pick it up. During the process when the courier will be traveling, the health facility will also be preparing for the sample, and then the courier just picks it and drops it to the next relay center. It's something that enforced effective communication, which actually makes the system efficient in a way that the 01:04:00couriers will not use the motorcycle or use fuel when there's no sample. That is one of the changes that we have actually made in the system, and by that we have also dropped about ten couriers because now the couriers almost--were now enough to cover without any gap using this dynamic system.

Q: Do you know what happened to them?

GRISON: They are still around and some of them were still gCHVs. Some of them they went back to the county, they were attached to the county, so some of them 01:05:00went back to the counties, the county health teams. But some of them currently they are still searching for something to do. But potentially, if at all we need to expand again, then they are the first people that we have to contact and say, are you still available? Can we take you on board again? Because they already know the system, they are already mature in the system. Of course, the criteria that we used to drop some of them is due to issues of delinquency whereby men as human beings, [laughs] they have shortcomings. Some which are related to abuse of the motorcycles, abuse of the fuel, non-sending of reports, delaying sending 01:06:00of reports. In the process of streamlining the system, this is the criteria that we actually used. So now, from seventy couriers we now have sixty couriers on board who are operating the system.

Q: As a coordinator, I don't know if you're able to form meaningful relationships with the couriers to any extent, are you? Is there a courier you could tell me about and describe for me?

GRISON: Yeah, essentially all of the couriers, all of the couriers, they know me quite well, I know them quite well. During the process of set-up, I interviewed 01:07:00them, I recruited them. Also, we did a major assessment recently where I got to meet all of them, I got all of their numbers, they all get my number. Whenever there is a challenge, they speak to me or they speak to--of course, before we recruited other Liberians on board, because when we started the system it was myself and some other expatriates, the replication team. We have what is called a replication team in Liberia. My focus was on sample transport, and we've got 01:08:00three other chaps leading on fleet management and then the head of the replication team overlapping both sample transport and fleet management. Before we recruited the other team members from Liberia, I was the main contact for sample transport, which means all the couriers would speak to me on any issues. I would try to solve their issues remotely, and of course I also had meaningful relationships with the county diagnostic officers, those are the lab contacts 01:09:00from the county level, and we would try to resolve any issues. They also helped us in the various trainings, especially the IPC trainings--they were also involved in that. They also helped in the recruitment process. So, the couriers know me, we interact, and we have a very good working relationship. Even the ones that we have dropped, they call me and I try to give them an assurance that if things happen to expand again then I will contact them.

Q: I know you have a ton, seventy and now sixty, but is there one who you could 01:10:00just randomly select and tell me about?

GRISON: Okay. There are a lot of them running through my mind right now.

Q: You could tell me about a few.

GRISON: Okay, I can tell you about the one we dropped. There's Jerome Teah. He calls him Jerome Teah. Teah is from Sinoe [County]. Okay, we currently dropped him. He's very communicative. He communicates. Fortunately, I get to know their tendencies, even though--I mean, my first contact with them, I managed to derive 01:11:00a lot of things in terms of their character and so forth, and the repeated contacts during training and assessments and some reports coming through. So Jerome Teah is the kind of guy that would communicate problems to me but at the same time, he would kind of abuse the system on the background.

Q: Like how?

GRISON: Like he would carry passengers, he would carry coal on the bike, and he would sort of abuse the fuel. His records were not really straightforward. But I got to know all of those things, but he would communicate to me every day. He would say, "I just called to say hi." It's common in Liberia that people try to 01:12:00circle you around whilst they're doing something that is very different. So Jerome Teah is one guy that would--and most of the time his motorcycle would have problems, engine problems, and then when you go to fix it, you make an assessment of the bike and you will see that it's got a lot of marks which show that--there are no foot pegs for the passenger, so the passenger will try to hang the legs on the swing arm. So you would see some footmarks, some marks. And 01:13:00then you would say, "Jerome, what is this?" Yeah, so, I know Jerome Teah is a person like that. Even when we dropped him off, it was because of a genuine reason and he didn't complain that much because he knew it was because of that.

I can also talk about Turnue. Turnue is from Margibi [County]. Actually, four of the couriers are from Margibi [County]. We have got Jerry Sackie, Turnue, we have got Aaron Kollie and the other fellow, but they are very good. They are 01:14:00nice, they are very obedient, they really take care of their motorcycles well and their records. If you ask them for any information in the process of tracking some samples, if you ask them any data, they would say--I mean, on their fingertips, which is very good. But one thing I like about them is that they are very smart, they do PLANS. Whilst everybody else is not carrying out plans, they are doing PLANS.

Q: Was there ever one time where one of your riders had to deal with a really 01:15:00difficult situation and managed it and maybe, I don't know, does that make sense?

GRISON: Yeah, yeah. You find out that most riders, actually, deal with some difficult situations at one point or the other. Generally it's because the terrain they are working is like, okay, the tropical nature of Liberia is very rainy. The issue of punctures, like they would describe, "I had a puncture, I had to push the bike to so-so place and then have it repaired and moved on." There are situations like that, and we would provide them some--would say okay, 01:16:00that's fine, can you make sure that you are safe? Go to somewhere safe and if you need to lodge somewhere, you can lodge there and we will send you some money for the lodging. There are situations where we had to do that, like when they have to transport some priority samples. They would actually call to say, I'm supposed to transport a priority sample. For instance, one guy from Lofa, his name is Abu. One day he called and he said, "I'm supposed to transport a priority sample, but the time here is around three o'clock and I know if I drive 01:17:00all the way to where I am supposed to drop the sample, at Phebe Bong Lab, which is around about three hundred kilometers, I know I won't be able to come back before it's dark. What should I do?" So I would say, "Okay, you can transport, but when you go to Phebe Bong Lab, drop the sample and don't go back. Find somewhere to lodge and we'll send you the money for the lodging, and then you go back the next day." There are a lot of situations like that, especially in terms of priority samples. They need to go to the laboratory as soon as possible, so couriers are forced to go, they are forced to go beyond their call of duty and 01:18:00make sure that they transport it. They actually understand the system to say if it's a priority sample, I have to do it, but they normally communicate first before they do that.

Q: Can you tell me about what it has been like working with CDC staff?

GRISON: Yes. CDC staff are very supportive in everything that we do as Riders for Health. The way they articulate issues is very impressive, especially with the other partners. The way they try to make sure we coordinate with the other partners, it actually makes us fit well and easier to settle down. In most 01:19:00cases, especially the first time when we came into Liberia, CDC was already on the ground, they already knew Global Communities, they already knew all the other partners who were involved, the ACCEL [Academic Consortium to Combat Ebola in Liberia] guys, those who were running the lab, WHO guys, so it was very easy for us to settle down. They would set us up for meetings, they would talk on our behalf in some of the meetings, which was a very good thing for them to do. They understood the system, they understood how the NGO system works. If there's any need for pushback, they would push back for us. [laughs]

Q: Do you have an example of one of those times?

GRISON: Several examples, actually. We had an instance whereby one of the samples was delayed to go to the lab, and it was during the weekend. The courier responsible had gone to church--

[interruption]

Q: Okay, let's continue, sorry. What had happened with the courier?

GRISON: Oh, the courier, I mean, it was on Sunday, so the courier had gone to church. I was called from the lab, then I tried to contact the courier and then the courier was not reachable. Later on, he called me back, and then he said he 01:21:00finally managed to transport the sample to the lab. It was the same day, but there was a lot of noise raised by the other partners about that delay in the sample. Actually, the courier managed to take it after three hours to the lab, and it normally takes about an hour to do that, but it really raised a lot of noise. It had become a very big issue with the other partners. In the background, of course, CDC would talk to the partners and so forth, and of course, we knew that CDC was doing a lot of background talking whilst we tried to straighten the system. That was one of the instances whereby CDC sort of 01:22:00fought for us. And we had some similar incidents, like in Maryland where we also had a delayed sample. It was over the weekend, but this was on a Saturday, and there really was no straightforward instruction to say the courier should work even over the weekend during an emergency. The courier, when he was contacted, he said, "My contract says I should not work over the weekend." [laughs]

[interruption]

Q: The Maryland issue, he would say "Oh no, my contract doesn't say that, it says I shouldn't work." The CMO was contacted, the chief medical officer of 01:23:00Liberia, he was contacted to say there's a sample here, sitting here, and this is what has happened: the courier cannot transport because he is saying "My contract doesn't make me work during the weekend." So I had to call the courier, I had to do a very quick call and make a quick response to the situation and made the courier transport the sample. I had to track the sample all the way to Tappita, which is the nearest lab from Maryland. And at the same time, give 01:24:00feedback to the CMO and the rest of the partners just to make sure that we are covered up. But it really raised a lot of noise with the partners and the CMO especially. But anyway, eventually, everybody was happy that the sample went to the lab. We still know CDC will do a lot of background talking. Of course, they won't come out openly to say "We fought for you," but we know, we really know, they were doing it.

Q: Who at CDC have you worked with most closely?

GRISON: From the beginning, I've been working with Suzanne [Friesen]. She has been very instrumental. She introduced me to the lab meetings. She introduced me 01:25:00to the IMS [incident management system] meetings. She introduced me to the key people in the Ministry of Health and other key partners. We also joined meetings together in the counties. I still remember the time we were setting up, we met in Lofa during the assessments, the feasibility assessments, we met in Lofa. We also met in Bong. We also met in Bong during that time. She's always supportive, she is happy to know what are we doing at which particular given time and 01:26:00whether she can help and whether she can come and see what we are doing just to make sure that we are doing the right things. And also how our processes are going on. I still remember recently we were doing the sample transport assessment, the review process that we were going through. She joined us in Margibi where we were doing the data assessments. She also got to witness the assessment process, how we were doing it, and she would come up with suggestions and also get to talk to the couriers themselves, of which the couriers were very 01:27:00appreciative of that. She is a great supporter of the system and she's a great supporter of the way we do things. Only to say, she's been there for Riders for Health, she really has been there. I cannot remember some of the instances that she actually joined us in the field--of course, the recent one, which is the retraining program that we are doing--

Q: That was this last weekend in Buchanan?

GRISON: Yeah, this was the last weekend in Buchanan. But I still want to think, 01:28:00there are several other instances that she joined us in the field just to make sure that we are doing things right. Also, she helps a lot with the documents that we design and plan, and with all the other plans that we do. When we come up with plans, documents, she always reviews them before we can start to cascade them or before we start distributing them. I appreciate her for that.

Also, other folks on the technical side, like John [M. Saindon], Gulu [Gwesa], they've also been working alongside to make sure that things are clear for 01:29:00Riders for Health. Picking out any issues, making sure that Riders is covered in one way or the other, especially in the relating issues where we really need to address to make sure that everyone is happy and the system is working quite as intended. This is how CDC has been, actually. And also, the director himself in the IMS meetings would talk about Riders for Health, to say Riders is doing a splendid job, they are moving samples.

Q: You mean Dr. [Desmond E.] Williams?

GRISON: Dr. Williams, yes. He's been quite supportive and has been talking about 01:30:00Riders for Health at those greater levels, national levels. He's spoken so much well about Riders for Health actually, which is a very good thing. And all other office staff, to say Christine [C. Dowie] on the grants management side, the co-ag [cooperative agreement], she's been giving all the necessary support. Of course, then you have the grants management, and she would give you the necessary data. We are very comfortable, we are very comfortable, we know we have sort of a mother to run to whenever we get in issues that we cannot solve. [laughs]

Q: Trunos, do you see yourself doing this work here in Liberia for the foreseeable future, or what are you thinking?

GRISON: Each time I go home to take a break, this is very interesting to work in Liberia. It's a new experience and it gives me so much independent decision making, so much initiative in the way I do things and the way I do processes and the way I design systems and the way I change them and the way I redirect some 01:32:00of the operations if need be. It has been a very great experience, and essentially that's one hundred percent on-the-job, although it comes with a lot of stress. Of course, I take one month break for every two months that I work. Yeah, I can see myself, if there are any other opportunities to work in Liberia under the same system, to say if there is another future funding for the project, which is likely to come to an end in August. Yeah, we'll continue to 01:33:00support the system in Liberia to make sure it works very well. It's one of its own kind, Riders, in terms of the way we have designed the system. It's very different from the other areas. For instance, the way we are trying to incorporate the fulcrum system, the telematics part of the system, the GPS [global positioning system], the fulcrum system, the level of coordination among the couriers in terms of calling each other, the way we designed the system to make it a relay system. It was really interesting. It is very good, it is very 01:34:00forward-looking, and yeah, it's good to continue developing it until it comes to a level where we feel that yes, this is it.

Q: And then you can hand it off to--

GRISON: Then we can hand it over to--

Q: To the Ministry? Is that who it will be, or other NGOs?

GRISON: Yeah, the final plan is to hand it over to the Ministry, of course. In any given set-up, the Ministry should be the ultimate owner of the system because I don't think funding should keep coming. There are limits to inflows of funding. At one point, grants will come to an end, but the Ministry should be able to take over and own the system and run the system. The other thing we've 01:35:00managed to do is actually to do the capacity building aspect whereby we have trained the Liberians to be able to run the system themselves. Currently, I have an operations manager that I really am working hand-to-hand with to make sure that he understands every bit and every part of the system, which I feel he's really picking up. He's doing it right. There are other areas, of course, that he cannot--he's still to learn, but most of the areas, I think, I'm comfortable, I'm comfortable with him doing it. Of course, when it comes to redesigning the 01:36:00system, when there are new challenges, yeah, then he would need a lot of help in that area. And also, of course, one of the other challenges is what we call the work ethics of Liberians, which is a bit different from the other countries that I know.

Q: What do you mean?

GRISON: The working culture is like, if I'm not there to supervise you, nothing will work. They need physical presence of supervision. Doing it remotely, it 01:37:00will not work. I believe it's something that will take time. Eventually, they will get to understand, but it's something that will take time to change that culture of doing things. Also, we have tried to capacitate the young people, that is if you see our staff, it's mainly built up with young people, which is not the case in all the other organizations in Liberia. This is because they were also affected by the war, whereby they didn't get that opportunity to go to school. So most of the educated people are older people, and those are the ones 01:38:00who occupy most of the offices. In this case, we said, let's capacitate the young people, let's train them, let's give them knowledge, let's give them responsibility to run the system. They are really on it. I'm impressed the way that things are going now, especially with the crop, the team that we have, it's very on it, it's very good. Only that, okay, they need time to shift in terms of the culture that they are used to. But eventually, they will get there. I can see them getting there.

Q: Is there any last thing that you would like to talk about that we haven't had 01:39:00the chance to discuss yet before we wrap up the interview?

GRISON: Not really, but I appreciate this--okay, already I've talked about the level of support that we are getting from CDC, which is really awesome. The way they have pushed things for us, not only in Liberia, but beyond Liberia. Okay, the local staff, we know also the other staff in Atlanta there, so they have really pushed things for us and especially during the time where we had to 01:40:00reapply for the grant. The way how it is is that the first grant was tied to our UK office, and then later on our UK office closed, so as Riders Liberia, we needed to apply for the grant, so it became a new grant. There's a lot of support that CDC has done to the organization. I would also like to say that sample transport is a very critical component in strengthening of lab diagnostics. At the same time, it's an expensive operation, which I feel the 01:41:00government might not be able to pick up at this stage, especially given that they are emerging from a very critical situation and they still need support in that area. Leaving it to the government itself, alone, the likelihood of failure is quite high. They still need support. Of course, a lot of things need support in this country. But looking at sample transport is--even in stable economies like Lesotho, of course Zimbabwe is no longer stable in terms of economics, but 01:42:00what I'm trying to drive at is that even in those areas, sample transport is a piece that needs a lot of support. Likewise, in this case, they still need to support the sample transport system until such a time when things are really settled down and the processes are all set, people begin to really understand that this is it, this is how the things are done, the government really understands that this is it, we really need the sample transport system, let's budget for it. I think, for now, it still needs that same level of support, more so because Riders is not picking from all the corners of the country. It's not 01:43:00picking the samples from all the corners of the country, and it still needs to highly incorporate other samples, which are the HIV/TB and malaria and so forth. There's still a lot of work to be done in terms of the sample transport. Once those are incorporated, and when we come to a level whereby we know that all the samples are coming from all the corners of the country, then maybe that's when things will be left to the government. But at the moment, they still need support for the sample transport system.

Q: Thank you so much for your time and for just telling me about your 01:44:00experiences and your work over these last couple of years. Thank you Mr. Grison.

GRISON: Thank you, thank you, much appreciated.

END