Carol Rao and Jennifer Liang

00:09 My name is Jennifer Liang. I am 44 years old today is October 19th 2016 and we are in Atlanta, Georgia. I'm here to talk to my dear friend Carol.

00:20 My name is Carol Rao. I am 46 years old. Today is Wednesday, October 19th, 2016.

00:28 We are in CDC in Atlanta, Georgia, and I'm talking to my friend Jennifer Liang.

00:36 So Carol, let's talk about how we met and how long we've known each other. You don't know.

00:44 How did we meet remember we met at REI is interview in December of 2014. There was there was what like five of us think they're about five of us who interviewed and I think we all saw who was going to make it or we are hoping we're hoping and so are ya after the interviews we showed up in

01:06 April for the yes conference and he is is the epidemic intelligence service. It's a two-year training program at the CDC. And we both pleasantly discovered that we were accepted and part of the class. I think that's kind of where it started. It was well and I think we're we that to only Asian Chinese American women think we were we were convinced everybody is going to get us confused or we're both too also generation.

01:39 So, you know we both been here now at CDC for 12 years. I can 1515 right? That's right because you were at the house before National Institute for occupational safety and health and what did you do there that was an industrial hygienist the Occupational Health protect the health care protecting healthcare worker than protecting workers and industries and Manufacturing mining looks like that until then when you started at CDC though, you were done something different. I was working on asthma and a indoor air quality and then I decided I want to make the switch and go to infectious diseases, which is how I ended up. Annie is and so wet e is what did you do? So I was in my cotix. So my background is in Infectious Disease start, my background is in and molds. And so I ended up in my contacts which is the infection portion and you ended up in parasitic diseases.

02:39 So my background is that I was a veterinarian interested in public health in and I had a natural interest in the connection and interface of diseases between human and animals are zoonotic diseases. And so I was fortunate enough to be working with a parasitic diseases as an Eis officer.

02:59 So then you know just to kind of Jump Ahead. How did what was your path? And how did you end up in China? So

03:08 So after he is in my contacts, I went to division of healthcare quality promotion to work on influenza A and influenza not protect healthcare workers from influenza, and I've always wanted to go to China being Chinese American never having been to China actually and then this opportunity you came open to work on infectious diseases with it International emerging infections program in China. So I went there in 2000 and 2009.

03:39 That's what they're for a six years until until 2015 and a 2015 and now you're back in Atlanta now, I'm back in Atlanta working on zika.

03:50 What are you doing for speaker right now? So right now I'm working on the usaid liaison for zika. So I'm based part-time in DC to work with usaid and CDC jointly on the zika response.

04:12 So then I think you know we're here cuz we wanted to talk a little bit more about not just speak of it as epidemiologist here and CDC. We get the opportunity to be part of agency-wide responses for things such as the aftermath of a hurricane like Hurricane Katrina. When H1 N1 was I threaten people were concerned about a pandemic and then of course it bolla and I know that the two of us over the past years have had various experiences in these agency-wide responses, and I knew that for you

04:55 One of the interesting aspects of it was your a bullet appointment. And so I was just curious as to why did you want to work on Ebola clearly there's an interest but you know at the time a lot was not known and people were scared. And so what was it about wanting to go to help out with the response and where did you go? So I was deployed to Sierra Leone in late 2014. So around October November and I was deployed from China that was based in China the time for CDC and my background is infection control. So it's protecting healthcare workers against exposures against bloodborne pathogens event against protecting them against diseases. So I think I had a special special expertise.

05:52 I really wanted to go and plus I I love outbreaks. I know that's strange but I love going on outbreaks. I love investigating outbreaks and we talked about this in the drink is too. I love working on the Fly.

06:09 And it's Ebola and there was a need dr. Freed and I just announced that that they were he was going to throw all of cdc's resources behind controlling Ebola volunteered and I put my name in and then within like a day.

06:26 Now Julie Harris calls me like we would love to have you let me affection control team as I ended up ended up going to Sierra Leone with in probably two weeks. And so getting all my scenes in place. I did not have a yellow fever vaccine site to get a Chinese vaccine.

06:49 Suez with infection control, what what was your role? What did you do? So I worked with work with a project book trying to that was I worked on a project that was training peripheral healthcare workers on protecting themselves against a potential Ebola patients that potentially might have Ebola to these were not places where they were known Ebola cases. So there are other people that already set up a training program to train those healthcare workers that we're working in Ebola care units and taking care of you both know any bowl of patients, but there was a group of people there were there were these healthcare workers in Sierra Leone that were the front line health care workers that potentially could become exposed to a person with unknown Ebola status. So as to train them on how to protect themselves, so we went we worked on this project with UNICEF and with an a Consortium of ngos.

07:49 In Sierra Leone in order to expand the project to the entire country in a short. Of time and how did they implement the training? So I was at a Cascade training. So we did Master training with design be along with ngos the ngos and UNICEF designed a Master Level Training and then we did the national Level Training and then that got disbursed to like the provincial level and then got. Spears to all of the provinces after that and how long were you there the first time when I was deployed in late 2014 I was there for about 6 weeks right late October too late. I'm sorry. I'm late September to around mid-november.

08:36 Until you said that that was your first time so you must have gone back so it went so I've noticed this with a lot of deployers is that if this is the type of work that people like to do people became very invested and felt very strongly and then felt very strongly about helping and working on it and also know when people are only two points are 4 to 6 weeks. He also saw like how much need there still was so almost everybody that I knew that had that type of feeling they came back they weren't they were back within like two or three months people that hated it of course never came back.

09:19 But in general I felt like almost everyone on you went back. At least once most people went back more than that. So then your second trip to do work on the same thing or what did you do? So my second trip when I went back in January to March of 2015 was to work on striiv, which was the

09:40 Which was the Ebola vaccine trial that CDC ran in Sierra Leone?

09:46 I cannot remember what strikes me too many too many and so working on that trial. What was your role were you in the field or were you helping with designing the the study? What was she what were you doing? So I was supposed to be one of the field needs and implementing the trial to be to start recruiting people into the trial and she start vaccinating people by the time I got there then everything took a lot longer than expected. So when I got there that it wasn't ready to be implemented. So the team lead take a look at what my background wasn't in China. Then a lot of diplomatic things work internationally. So I was assigned to be the the policy liaison with what Sierra Leone Sierra leonean the Ethics Committee to work on the IRB and also with Sarah Leons FDA to help get the protocol through their FDA and get approval.

10:46 Integrated s i r b i r b is

10:52 What is IRB integrated research for my God? I don't know if it's a board that tries to make sure that's

11:06 I'll be worth two in the afternoon. We were told not to do this. So I R B is institutional review board. So it's the group within a within an academic are within a research organization that reviews all work that is done by that involves human subjects to make sure that it's at the Google you can make sure that that the guy that has everybody knows what they're doing the people are participating. So it's ya so I did that which was very different than my first one and at the point at that time. I think I was a little disappointed. This point is not the right word. But I really like doing fieldwork. I like being out in the field. I like working with people. I like Gathering data analyzing data, and now I'm basically sitting in at that time or office that was in the hotel with the Radisson Blu.

12:01 Dealing with phone calls back to Atlanta and trying to coordinate usfda is comments as cdc's comments and RPI comments, so

12:15 But I felt like I accomplished something on the last day.

12:21 The last day I got Sierra Leone IRB to approve the protocol and I was so happy and cuz I was going back and forth back and forth and the way that they're their IRB chair was that he did not like it. When was CDC just kept every 4 to 6 weeks had to deal with a new person. I've just felt like it would be detrimental to the project if we waited for another person to come on board for CDC to get this proper protocol through their IRB.

12:56 And so I basically went there and I could gauge his like I can gauge his mood is like so this is very similar to the first one that you've already reviewed. And these are the changes that were made and this is why we think that this is not these are not major changes, especially that would affect anybody's a Hyuna and human subjects research issues.

13:24 What's the likelihood that you could sign this before? I leave his ass. When are you leaving? I tell him he's like come that morning. So I went that morning went over but I get our car headed it to me and I gave it to her team lead and then I got on a plane and left.

13:43 I was a huge accomplishment a huge accomplishment accomplishment even just for the there were a lot of delays and I think that there's clearly an interest in wanting to develop a vaccine and see that works in the field. And so to be able to do what you did. I never I've never done that before so it was a learning experience for me. I'm not a regular for a person so I became a regular short officers idler all of the rules for how to pass a investigation new drug trial through their I threw their FDA other Food and Drug Administration. So that was that was interesting.

14:26 Do you also were you also were deployed for Ebola? What was your deployment like and what was your deployment? So for me because of my family I chose not to and be deployed in the field. And so what I did was I worked in the emergency Operation Center here at CDC and my role was to support the team that was doing that post monitoring a post deployment monitoring what this was for any of our CDC employees who were deployed in the field. I'm going to a bowl affected countries. There was a lot of concerned about the safety of our of our deployers and wanting to make sure that when they return to the US if they stayed healthy and if there was any potential symptom or any sign of a bullet that we would be able to respond and CDC would be able to provide the appropriate Medical.

15:25 Response and throw my job was to make sure that all of you coming back were taking their daily temperatures and monitoring their symptoms for 21 days and it was an interesting experience just because in some way it felt like being a mother hen. It felt like trying to make sure that everybody take their temperature in the morning and in the evening and report it to CDC via email. And so sometimes it was it would be noticing that certain people that I knew weren't being timely and their responses and making that personal connection via email saying hi Carol. I noticed that you've been back for three days and you haven't reported your temperature for this day. Could you please send them in?

16:17 And so that was my my role in the Bible that response. I do remember getting those emails from you because I was not that good but I do also want to say that I appreciate that role that you talk in that CDC took people ask me when I when I first went was I scared and I was scared even though I've been working for CDC for over 10 years at that point. I been on multiple multiple outbreaks Ebola seem to be very different than what we had what we had experienced at this specially this particular outbreak as hell when I got on that plane and Beijing to go to Sierra Leone, I was scared.

17:01 But I also was pretty confident that CDC would never put me in in danger and that they would protect me and if anything were to happen to me, they would assist me. So I do really appreciate it. Even though I wasn't very good at reporting my temperature. Well, thank you, but I did report you did and I also did have three vomiting incident instances.

17:30 Once one of the first time when I went and I think I got food poisoning in Germany on my layover on the way to sterilize a way to Sierra Leone the first time and I was like

17:41 They take temperature that people are going into Sierra Leone. Do I really want to go to an ebola Holding Center on my way into Sierra Leone when I know I don't have Ebola. Of course. I'm yelling like Tylenol before I get off the plane if I may try to have a temperature and like I just ran like walk through that was it and then I also got sick once when I was in the hotel like so I was deployed in in Freetown.

18:11 And I was pretty sure it's due to a malarone to the mail run how I took them out around that morning. But of course you have to report it. So I reported it and then sequestered myself in the hotel room for today. Just just for the day by the evening when I felt better. I never had a temperature but you know, you're supposed to report the symptoms, but the worst one was when I went back to China after the after the second one and on the 20th day.

18:42 I had a vomiting incident.

18:45 I'd like to my mine should I report it was I not report it. You do not know how many times I've said the people I do not have Ebola.

18:55 And okay, I should be responsible cdcr and reported.

19:01 So I did what happened, so

19:07 You know, there's not that money 46 year old female epidemiologist based in Beijing.

19:14 The Privacy was not really at all there. I just thought I do, you know, it'll be something else. I got an email from people. Like is this you like? Yes, that's me.

19:24 But I just remember I like the day before I had lunch with a friend and I was like did you get sick and she's like no, I didn't get sick. She's like are you okay? I'm like I don't have Ebola.

19:35 But yeah, I'm so but I did the right thing and reported it and everything was fine. But I think there was a little bit of fear, but I also live in it. I live in a foreign country where there's food safety issues. So

19:52 Getting food poisoning is not I got food poison on the way to Germany. So so just thinking about when you were deployed I just kind of laugh at the fact that you once you found out that you were going. I remember your excitement because you were going to be able to be in the field and you were really excited to be contributing to the response and you would send out these emails to all of our friends just kind of letting them know how you were doing and kind of giving us updates about what some of the things that you do interesting things that happened. But what I remember the most from these emails, I don't remember all the details, but what I remember most from these emails with the was at the very end you made us all promise not to tell your parents and not to tell your family that you were deployed to Anibal affected country all specifically my mother.

20:52 When I decide to go, like I said, I was a little scared and we were very given all this information about like putting your will in order and it just getting everything ready in case anything were to happen. And I made the decision like I did have to tell my sister in case something were to happen. So I sent her all of my information like my will my access to my bank accounts all these things in case anything were to happen to me and I say do not tell the parents do not tell my parents do not tell their parents.

21:29 And I died because as as you with a Chinese mother knows.

21:39 They would not have appreciated why I was doing this and so I did not tell my mother until after the last time I went and and because I also had to they were asking my sister why I wasn't calling them why they weren't hearing from me. So and me and my sister did tell them what was their reaction. So I talked so I called my mom has already home and in Beijing, after the second as I called my mom and I were talking and I thought you know, I was in Africa. She said yes, she said she liked is everything. Okay? I said, yes. She's like I was so scared for you and I might not know it. Everything is fine. And she's she said I was so scared you were going to get that you were going to get kidnapped by ISIS.

22:26 I like okay out of all the things you could be scared by Sierra Leone. That's what you're scared about the Chinese especially Chinese mom in Chinese when they have they have different views of risk when I told I have a Chinese housekeeper when I was in when I was impatient and when I told her it was taking care of my take care of my house while I was gone cats and my cats and when I told her that I was leaving to go back a second time. The only thing she said to me was but you just got hello again.

23:03 Do not like protect yourself against Ebola. Don't do this. Don't do that. Don't get tan. I think I can do that.

23:14 So how was it for you coming back? I know you talked about going out to dinner with friends and telling them that you didn't have a bowl of but I mean did people in the office see you differently or treat you differently here. So I went back to China I didn't I didn't I did not Transit. I did not come back to the United States owe in China. It was not as hyped up. I would say it was as it was in the United States. It wasn't on the news all the time. There wasn't this fear-mongering that went down in China. So I think there were it was more the Americans that were scared the Chinese like whatever they don't hear it on the news, but the Americans that I work with and the Americans that were particularly at the embassy that would hear all these things is watch CNN and here are the news that they were they were people that did not want to meet with me. Talk to me for for 21 days.

24:10 Didn't want to have dinner with me nothing, but I was allowed to go to the office and buy.

24:21 I was

24:26 I would say that.

24:28 The embassy Embassy tried but there it's just a lot of fear. So the the med unit of the medical unit that doctor there had no problems with me it because we talked about the what risks I had of exposure which were very low right very low, right and I don't

24:47 It just seems unlikely that I would have any risk of Contracting Ebola. But now going back to China itself was a little interesting the first time because I was I would have stuff.

25:03 I was the first US Diplomat cuz I was assigned to the US embassy at the time when I was in China. So I was the first US Diplomat to go from Sierra Leone or to any Bowl affect the country back to China and there was a lot of discussion in November of 2014 about how I would be treated by the Chinese when I entered the country. Would I be quarantined with a put me in a room and take me away and a lot of hand-wringing on the on the on the US Embassy side and

25:41 Yeah, so I just and I remember my supervisor at the time ask me what I prefer to go to the United States first spend my three weeks in the US and then go back to China. And at the time there was a lot of a lot of hyper-vigilance about about people returning from this will affect the country's to Atlanta specifically if I'd heard friends whose children were pulled from school and people being put in tents for their 3 weeks for a minor for a slight slight fever. So I made the decision that I'd rather risk going back to China.

26:21 Tell us about our tell me about you know, you've your plane landed and you're going through immigration and what happened. So so before the plane lands with there was an announcement in English that anybody who had symptoms of fever vomiting or physical symptoms of Ebola to please identify themselves to the to the flight attendant in Chinese. They meant that they said all of that and if you had been to any of these three countries, so Guinea and Sierra Leone

26:59 My time, so I made the decision at that time that I do not understand Chinese and that I would not speak any Chinese while I was going through customs and so they asked me why did you identify yourself? I would just say well in English. All I was asked was whether or not I had a fever and I didn't so I just went through and has no problems, but there was a lot of concern I think because they were actually so the Chinese actually were holding Africans that it returned their own staff were being quarantined in a separate location, but I was not a kind of fluid under the radar.

27:44 Why do you think that the announcements were different and I'm not clear why the announcements were different and why they said something different in Chinese and English. I think they were not anticipating that a lot of English speakers would be coming through that way. So it's not like there's a lot of Aid workers or like not a lot of American businesses are English-speaking businesses where we're going would be going from Depo affect the country's back to China, but the Chinese have a lot of a lot of companies and a lot of state-owned Enterprises that you work like Mining and things in Sierra Leone and in Liberia, so there were a lot of returning Chinese workers that potentially were exposed as I think during that announcement. There was more concerned for these Chinese workers that were returning rather than these International people that were returning because it's you know, I work for an NGO I wouldn't be returning to China.

28:44 And if I were returning most like I was speaking Chinese, so I think that's why the the the the announcements were different.

28:55 So do you think your experience is in Sierra Sierra Sierra Leone?

29:03 I guess how did you feel cuz I know going there clearly within going to someplace where I don't think you've been before and given the circumstances in the situation of the bowling and you know being scared about what you were going to be facing or doing.

29:21 After your experience coming home, like what did things change did you feel differently like what it do? You know you need after returning back to China experience working in these countries and in working on something that is still you know, it's a scary topic. It's a disease that again we don't have a yet have a vaccine for and it's fatal and it's a lot of people are scared about it. So yeah, how did you feel coming home?

29:52 Adult I felt very

29:56 Grateful that I had this opportunity and I did do feel like that I contributed and that's always that always is a reason why I like to go to these things because I feel like I have a have a skill. I can make a contribution. I can make a difference.

30:13 Like when you're on the ground in that situation, it's it's overwhelming because there's just so many things that need to be done and like so when I went back the second time, he was still be the same two months later. It's as if nothing has changed other than cdc's like level of bureaucracy, but but we are on the ground and I feel like things are exactly the same and after all that every have been pumped into it not going to still be the same as the effort was overwhelming the things that need to be done were overwhelming. We were working 12 to 16-hour days and soon as I wasn't even sure I like what we could accomplish during that day. So the way that I would the only way that I could do it was to take just a little little steps. I do hit today. I'm going to accomplish this and if I just do this one thing that's one step forward because if I if I looked at the entire thing and like the entire outbreak the entire response.

31:13 Because I need to be done from miscommunication and your treatment keratin treatment and infection control training liaison. It was overwhelming and

31:26 And then the other thing is that

31:36 So how does this compare to other responses are deployments Eve done?

31:43 This was really different in many ways. I've done a lot of a lot of outbreak responses. And this was the first one in El West Africa. So this person might have been to West Africa to identify other African responses in in Kenya, but this is the first time to a situation like like in Sierra Leone as far as their level of development and the extent of the outbreak and the severity of the disease, but the other thing that was that was different for me for this outbreak was my interaction with the Chinese and so this is the first the Chinese set up a laboratory and an ebola Care Unit or gold Holding Center in Freetown. Basically at the same time that I I was there and this was what was happening in these countries was definitely a multi-country effort. So we had Canadians the British.

32:43 South Africans Americans Chinese and all trying to work together to to try to control the outbreak.

32:54 So this is the first time that the Chinese had ever been to Ploy to an international outbreak to participate as a as a as an equal partner that they'd always gone before as part of like a waho waho deployment. So it always under another group that they would get they would add a Chinese person but they'd sent a 70 person team out to Sierra Leone the set up the table and to set up the to set up their Hospital.

33:23 And nobody knew what they were doing. So we had this in our control center that had all of the partners in all the international partners with the Chinese. They would send somebody but it wasn't really clear what was going on. Cuz I Chinese tended to be very insular. That's just the way they do it that even went even in their work when they have their mining. They they bring all their own workers. They bring their own food. They bring their own equipment. Everything is they very rarely interact with the with the local community and I think that's when they went in for this outbreak. They can't have you had a little bit of the same atom. They're just going to go and do their thing be very insular. But this is part of it massive International response. So I was asked to be the Chinese liaison to work with the Chinese and interact with them to find out more about what they were doing to try and bring them in to the international response.

34:21 So do you think your work in China working and being familiar with the Chinese government that helped acting as liaison the definitely it definitely help with acting as a liaison because a lot of the people that were in the field is zero, there were people that I work with in China. So we already had a working relationship and and my Chinese is probably not the best I would say I would say when I went there when I first moved to China 2009. I spoke like a five-year-old and I'll by the time I came back. I probably spoke like a 12 or 13 year old. So I did a lot of translation at the time cuz if there was really not very many people that could that spoke both Chinese and English and so I did a lot of translation and one of the first things I remember doing the first day. I landed on the ground we went to go visit the Chinese lab that they had and and I

35:21 I did the translation and we went to go see their hot lab. We weren't jingle and we saw the video they're hot lap and trying to explain how their samples were processed. And I just remember not knowing the Chinese word for centrifuge and having to say it's that thing that you put the tube in that spins really fast.

35:43 I got just I don't have these technical terms in Chinese. I ate but they understood it and said it was fine. But I never had to use my tities so much brakes outbreak.

35:58 So you're back from China now if how is it been like being back in Atlanta?

36:06 It was a difficult transition being out in the field on the field not in not in not at the city's so not being at the CDC mother are being out in the field is very different very independent on not that much oversight. We get a lot of decision our own decision making and then coming back here and being basically a little fish in a big pond has been a difficult but now I'm on Ebola and so I've got still I'm sorry. I'm now I must see that's right. Now I'm working on zika and I thought I get to still have my response experience and to do my outbreak response that I enjoy so much every time every time I do it. I'll break I say, this is the last one. I'm never doing another one every single song.

37:02 I'm not going to hold that to you. I would let I hope that part of the move back has been made better by all of your friends here who Evan S Corp glad that you're back. Yes. I am happy to be back in the US people asked if I would ever know if I want to go back to China and that was at work was great and I really enjoyed it. But I think I I really enjoy being back in Atlanta being back in the United States. Well, I know I'm happy to hear back and my kids are too.

37:41 Love hate relationship. Do you have an outbreak because in the shower, you said I love them. I'm never doing what I do. Usually so usually so why I said that is why I have said before for everything to operate that this is the last one. I'm never doing another one in addition to I love Al Briggs this always frustrations without brakes and when you're working on on one end and you're in the field and you just want things to work, everybody should be working together towards the same goal or the same the same thing and I think everyone over all is but on a day-to-day basis, there's always these frustrations. Why don't I have this piece of equipment yet. Why doesn't this why isn't training starting now, you know, why isn't the money to this person? Why why aren't why are there surveillance officers getting paid if they're not getting paid? They can't report this evening. Are they?

38:41 For the cases and so the day-to-day frustration can be overwhelming also as so there it is and also happens when the very beginning. I'm so excited to get there. I so excited to get on the plane get all my stuff all this excitement to get on the ground first couple of days. Why am I doing this again is literally what I'm thinking the first couple of days why why did I do this? Because it's like drinking from a water. It's like drinking from a fire hydrant or fire hose. All this information is coming at you because there's a person is on their way out and they're trying to transfer all of their information to you in a short. Of time. You're trying to take everything in not only trying to figure out what the situation is, but what your specific tasks is coordinating with everybody else. It's you know, there's a massive for a bullets it wasn't it was a massive massive effort.

39:39 So the first the first few days, usually why why did I agree to do this again?

39:48 Are you kind of figure everything out and you know, you working you working you work and then be up by the time you're leaving everything kind of is is okay and everything works out and things move forward but usually in that first couple of days, I remember one time I was on the phone. This is what I did a rift valley fever outbreak. I talked to Danny if I can do it. I don't care if I never do another outbreak, that would be okay by me.

40:17 And then a month later, where am I?

40:25 So and I think a lot of what I think a lot of what we do and as epidemiologist, we do spend a lot of time in the office answering emails writing email writing protocols writing guidelines. And so going out to the field to me was always

40:46 I just felt like I could make an immediate difference. I don't know. How do you feel about going on to the field now? I think I feel the same. I think you know, it's the work that we do here, you know at the mothership. I think sometimes it does feel a little bit isolating and we are at the national level but to be out in the field and to interact with partners and collaborators or even to see and interact with the people that we are trying to help. I think that that's that inspires us to keep doing what we're doing.

41:23 So thank you Jennifer for doing this for Dewey storycorps with me. I really was so happy that we can find a time to do it together cuz I really wanted to do it with you now, and I'm glad too and I think that I just know we talked about her experiences all the time but to sit down and really just focus on it. I think it's been it's been fun.

41:45 I think you