Dr. Barbara Marston



MILLER: This is Dr. Bess Miller, and I'm here with Dr. Barbara [J.] Marston. Today's date is August 1, 2018, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Marston as part of the oral history project The Early Years of AIDS: CDC's Response to a Historic Epidemic. We are here to discuss your experience during the early years of CDC's work on PEPFAR, the President's Emergency Plan for AIDS Relief. Dr. Marston, do I have your permission to interview you and to record this interview?

MARSTON: Yes.

MILLER: Barbara, you've worked on the HIV/AIDS [human immunodeficiency virus/ acquired immunodeficiency syndrome] epidemic since your early days as a medical student, resident, and then Infectious Diseases fellow, as an AIDS clinician in the earliest days of treatment, for CDC and Kenya, pioneering the scale-up of ART [antiretroviral therapy] in Africa, and then providing scientific leadership 00:01:00at CDC headquarters, implementing PEPFAR programs and piloting and scaling up cotrimoxazole preventive therapy and other treatment for opportunistic infections and tuberculosis. You have also provided vision, scientific direction, leadership, and management for a number of the highest-level CDC international public health programs, including the coordinated public health recovery activities in Haiti following the 2010 earthquake and ensuing cholera epidemic, the International Task Force Emergency Response to the Ebola epidemic, and the post epidemic recovery capacity expansion in the West African countries of Sierra Leone, Liberia, and Guinea in 2014-2016. We have a lot to talk about. Let's begin with your background. Would you tell me about where you grew up, 00:02:00your early family life, and then where you ended up going to college?

MARSTON: I was born in Massachusetts, but we moved early to Pennsylvania outside of Philadelphia, and I grew up there. My dad worked for GE [General Electric Company]. They have a big office in Valley Forge. Then I went to Franklin & Marshall College, which is not too far from there. It's a liberal arts college in Lancaster, Pennsylvania.

MILLER: Who or what influenced you to go to medical school, and where did you end up going to medical school?

MARSTON: I'm not really sure. I wanted to be a doctor from very early years, as long ago as I can remember. I got a little bit of taste of public health because I was sixteen during the Bicentennial and the Legionella outbreak in Philadelphia, so I had some awareness of people coming in and investigating that outbreak. In fact, the F & M choice was because they had a reputation for being able to get people into medical school. I ended up going to Temple [University]. I didn't know how I was going to choose. Pennsylvania had a lot of medical 00:03:00schools. I wanted to go in Pennsylvania because it was less expensive and I'd have a better chance of getting in. I didn't know how I would choose, but when I went to Temple, it definitely had the right feel, and I ended up going there.

MILLER: What years was medical school? Were you actually seeing AIDS patients during your medical school experience?

MARSTON: Yes, that was 1982-1986. It was right during the time when there was growing awareness about HIV. It was quite common for a patient to come in very ill -- what was it, what was it, oh, and eventually it would work out that (this patient) was a gay man and that what he had was Pneumocystis pneumonia and that this was this immunodeficiency that had been described. It was a time when people were very uncomfortable talking about it, uncomfortable being on the same floor as the patients with HIV. We had very limited treatment to offer at that time.

MILLER: So, you were seeing some gay patients with pneumocystis. Any other types of patients with other diseases that we came to understand were part of it?

MARSTON: That was honestly the main one. There were a few patients with Kaposi's sarcoma, but pneumocystis presentation with pneumonia that eventually turned out to be HIV-associated was by far the most common thing.

MILLER: Where did you do internship and residency, and what about AIDS during that experience?

MARSTON: For residency, I went out to Portland, Oregon. I had an advisor at Temple who felt that if you didn't need to stay in the same place and you could go elsewhere, you should. He said medicine was different in different parts of the country. I thought I had no reason that I had to stay in Philadelphia, so I really looked at the West Coast and very much enjoyed the Portland program when I interviewed there. My clinical work there centered around HIV, obviously. We did a range of inpatient training, but my outpatient clinic was an HIV clinic there. I had continued experience, and it was much of the same thing. That was 00:05:00now from '86 to '90, so we were evolving through having some treatment, for example, for pneumocystis. (We were) beginning to have AZT [azidothymidine] available, but it was the time at which AZT would make you live longer but not necessarily better. We really didn't have effective antiretroviral therapy then.

MILLER: Again, was it the same patient population? Was it mostly gay men with pneumocystis, or at that point were you seeing a broader array?

MARSTON: It was still dominated by gay men. Of course, there were people that had other risk factors. I particularly remember a patient that had acquired HIV through a blood transfusion. That was a very difficult scene. He presented to the emergency room actually with a rash from cotrimoxazole that he had taken because he hadn't felt well. He had thrush, so it was fairly obvious to me what might be going on. We couldn't get results immediately, but I had to at least 00:06:00raise the possibility both to him and his wife. It turned out she was also infected. That was one of the examples of a tragic --it was very shortly before there were blood tests available. If he had his heart surgery delayed a few months, he probably would have had a safer blood supply.

MILLER: Do you remember the experience of actually telling people that they had HIV, and how you went about doing that in those early years?

MARSTON: Yes, absolutely. Most gay men by that time had lost multiple friends. An understanding of the possibility of HIV was pretty common within that population, but it was still a very difficult thing to broach. I remember talking to my program director. One of my outpatients who wasn't in the HIV clinic was just there to be seen, but he also hadn't been feeling well. He had 00:07:00thrush, and, of course, I knew right away that that was likely going to turn out to be an HIV diagnosis. It happened so frequently that it was pretty taxing emotionally, even for me. Of course, I'm not the one that's sick, but to see that many people sick and dying was difficult.

We had a lot of challenging issues with things like should you put somebody on a ventilator. There were people with very strong feelings about whether that was appropriate for someone with HIV or not. Again, we were just in that cusp where maybe somebody could get treated for pneumocystis and come off the ventilator. Most people didn't, and that's what was behind people's feelings about it not being appropriate, but it was the evolution of at least having some treatments available for HIV.

MILLER: Was there concern about infection control, in terms of putting these patients on a ventilator?

MARSTON: Probably, yes. People had the widest range of feelings about infection control. Some people were cavalier and wouldn't even wear gloves, to make the 00:08:00point that they were comfortable with people with HIV, and then there were people that were so frightened. Again, they wouldn't go on the same floor as a patient with HIV, so (there was) a lot to try and navigate, among especially healthcare providers but also among family and friends.

MILLER: Were these patients kept in private rooms, or do you remember an evolution of how these patients were cared for in the inpatient setting?

MARSTON: It was mixed. Our residency was at a combination of the university hospital and the VA [Veterans Affairs] Hospital in Portland, with a few experiences of private hospitals. The VA was largely four-bed wards at the time, although they opened a brand-new VA in Portland during that time. Then there were mostly private rooms, so it wasn't really driven by the HIV, it was more driven by what was available for everybody.

MILLER: This was Portland, Oregon.

MARSTON: Yes.

MILLER: You mentioned the Legionnaire's outbreak, but (were there) any other 00:09:00things that impacted you that got you interested in public health and decided to come to CDC?

MARSTON: There were a few people in my residency that had had experience doing public health or working at CDC. [Dr. Thomas J.] Tom Torok in particular had gone to that same training program and then done EIS [Epidemic Intelligence Service]. I got in touch with him and got some information about how to apply. I got pretty excited about it, which was a little bit of a shift for me. Even though I had wanted to do medicine, I envisioned myself more as an emergency room doctor. That switched during medical school to internal medicine, and then this public health idea became pretty exciting to me. I applied to EIS, and I remember very clearly when I got the call. It was from Patsy [R.] Bellamy, who had one of the strongest Southern accents that I can remember. I wasn't necessarily able to understand her well when she spoke, but when she called with the news, she was obviously very excited, and so I assumed it was a positive 00:10:00response. At the time, I was cross-country skiing on the back of Mount Hood. This was in the days of very, very early cell phones, but I carried one because I was on call for the residency. The phone was, you know, this big (holds hands apart) with the extra-long antenna to go to Mount Hood. There I was with the snow and the pine trees, thinking, what am I doing going back to Atlanta? Actually, going to work for CDC was really pretty exciting.

MILLER: So, you got to CDC. Where was your EIS assignment, and what did you do during your EIS?

MARSTON: That was a (bit) complicated. It was the time that they -- you've probably heard this about the match. It was described to us as you would get matched with the highest position that ranked you, but in fact, there was a little bit of a global happiness algorithm. I had met [Dr. Ronald J.] Ron Waldman at the time. I was struggling between whether I really wanted to focus 00:11:00on a research-oriented position or more of a program implementation situation. He was very strongly in favor of the program implementation side and basically convinced me that I should at least consider the International Health Program Office [IHPO]. In the end, I decided no, I'd prefer some of the bread-and-butter enteric diseases, respiratory diseases positions, and I ranked them the highest. I ended up matching with IHPO. I know it was a little bit of the global happiness algorithm, based on what people have told me since then. Also, right before the match was announced, I was told I could switch to any position that I wanted that was still open, so I had the impression that they had done something a little bit unusual.

I have to say, how it evolved was I worked in the International Health Program Office for about six months. Then one of the people in the positions that I had more strongly desired had to leave EIS, and they let me switch to that position. 00:12:00I am one of the very few people that did EIS in more than one position. I think if somebody had offered me at the beginning: would you like to do six months of international work and then the rest of the time doing respiratory diseases with [Dr. Robert F.] Rob Breiman, I would have said yes, absolutely, so I have to say it worked out pretty well.

MILLER: What did you do for the international assignment?

MARSTON: I did a couple of different projects. The first one was--enhanced surveys were just starting in the U.S. then -- well, not starting. The idea was starting that they would take NHANES [National Health and Nutrition Examination Survey] ideas and maybe do those in an international context. There was going to be a survey like that done in Pakistan. One of the questions was, "Have you been immunized against tetanus." That turns out to be a very complex question, because it's not just "have you received the vaccine?", it's "have you received two in the last two years and are you covered for--?" There was an uncertainty about whether the answers to that question would be valid, so we wanted to do some work understanding whether women could accurately report whether they had been immunized against tetanus. I was supposed to go and do a survey to 00:13:00understand that question. As it turned out, I was in Pakistan at the time, just after Benazir Bhutto had been deposed and new elections were coming, and so the plans for the --There was going to be a trial of the survey that was delayed because of the election. I was supposed to do the trial survey and then compare to some clinic records that were supposed to be very high quality. The records turned out to be maybe "high quality for Pakistan," but extraordinarily difficult to understand. Then the survey wasn't done, so the project was a little bit underwhelming scientifically.

MILLER: Did you go over to Pakistan then?

MARSTON: Yes.

MILLER: Was that your first international experience?

MARSTON: I would say yes. I had set foot over the border of Mexico and in Canada in Niagara Falls, but I remember flying to Pakistan, thinking, I'm not even sure this place exists.

MILLER: How did you do? Did it give you a real taste for international work or--?

MARSTON: It was a tricky situation. I went with somebody who was working on the survey, but he actually got off in Lahore and I went on to Peshawar by myself. The person who I was working with there picked me up. I think he was very surprised at my age, which at the time was thirty. All of a sudden, he had a fairly young American woman on his wing, which was a status symbol. I was instantly a status symbol during the course of the time there. Because I treated him politely, I think he thought that I was in love with him. He did sincerely ask me to marry him, so that was a fairly uncomfortable working situation in that regard. Also, I expected to perform well scientifically, and like I said, there were some challenges that were beyond my control. I wasn't sure how this was going to be perceived when I got back.

The other thing that happened, there was a major earthquake while I was there. I 00:15:00was in -- I hired a few women to do a sub survey just to get the tetanus information from a group of people. I was staying at one of their houses, and that's when the earthquake happened. At the time, I was in a bedroom, speaking with an older man in the family who had a broken hip. The lights went out and the walls were shaking, and I went, this must be an earthquake. Then I thought, you're supposed to go outside or to a doorway, but I didn't have any instructions in my mind for what you do if you're in a bedroom with a man with a broken hip. Luckily, it was blissfully brief. By the time I even thought about what the possibilities were, the shaking had stopped, so I was able to stay there with him. Anyway, it was a big adventure. When I got back, Ron Waldman and [Dr.] Michael [S.] Deming both said, we were just really seeing if you could get across the airport. They didn't seem too frustrated by the quality of the science. We didn't learn that much about it. I can tell you that women cannot 00:16:00accurately tell you if they're immunized against tetanus.

MILLER: Oh, my gosh, that sounds extremely eventful. Any strong memories from your EIS experience in the Respiratory Diseases Branch?

MARSTON: I ended up being the surveillance officer for Legionella, so that was a full-circle experience. That was exciting for me, and then working with Rob Breiman was also a great experience. We did some difficult work trying to understand the etiologies of pneumonia. The work was in Ohio, but it was really an effort to understand at a very detailed level what are the etiologies of community-acquired and classic pneumonia. For Rob, we had a budget like this (small budget), and his idea was about like that (large budget). We were always scraping and stretching, but we got a lot of good work out of that. The other experience was, [Dr.] Kevin [M.] De Cock was the Country Director in Côte d'Ivoire at the time. He'd come back for a meeting, and somebody asked him, "With what we perceive as all the HIV in Africa, are you seeing a lot of 00:17:00nontuberculous mycobacteria? Are you seeing a lot of Mycobacterium avium?" He said, "No, we see a lot of different non-tuberculous mycobacteria--like Mycobacterium ulcerans." I ended up doing an outbreak investigation of M. ulcerans, and that meant that I got to meet Kevin and also see some of the work that was being done in Côte d'Ivoire at the time.

MILLER: Did you learn something about what you enjoy most, or did you enjoy all of it?

MARSTON: I think that's my problem, right? I've never really wanted to close any doors. As far as I'm concerned, if I can do a little bit of everything, that would be fine with me. At the end of EIS, I actually was offered a job in the TB [tuberculosis] group, but there was a big part of me that was afraid to give up clinical work. I had been in touch with the people at Emory [University] and talking about possibly joining their fellowship program. In the end, that's what I decided to do after EIS, because I was afraid to give up clinical, not because 00:18:00I didn't enjoy the public health work. So, I did, and then I went on to do the Infectious Disease fellowship at Emory and did clinical work for the next several years.

MILLER: This was, I guess, 1992, and your fellowship was at Emory in Atlanta. By this time, the AIDS epidemic is full blown. There are three hundred thousand AIDS cases that had been reported, and still over half of them have died. There's some AZT treatment. What did you experience regarding HIV/AIDS during your fellowship, and were you focusing on that group?

MARSTON: Rates of HIV in Atlanta were high, and the clinic -- I worked in two big clinics: at the Grady [Memorial Hospital] HIV Clinic and also at the clinic 00:19:00at the VA. Both were very large, a mixed population, and with respect to what we talked about before, some gay men, some drug users, and a few people with other risk factors. It was very difficult work, because we had very high rates of death. I think at the VA Clinic during that time, we were getting about a death a week out of -- I'm not sure how big the population was then -- maybe about a couple thousand patients in that clinic.

We did have things to offer, and it was during that time that we started having a little bit more to offer with respect to antiretroviral therapy. I stayed on after the fellowship as a faculty member. It was, I think, 1995 when we really saw the first time when 3TC [lamivudine] was available. If you gave somebody AZT, maybe they died more slowly, but if you gave somebody AZT and 3TC, they 00:20:00actually got better. It didn't last very long because of resistance issues, but that was the first time we'd seen anybody get up out of their wheelchairs and go back to work or get out of bed or that kind of thing, so it was really exciting. Then we were involved in some early trials of triple therapy, so we had a few patients who were getting triple therapy and the protease inhibitors as what we could use at that time. That was just -- it was a sea change for the clinic. After the 3TC experience, we got triple therapy essentially the next year. I would say in '96, we got everybody on triple therapy, and the death rate went down to more like two a year instead of fifty a year. Just an amazing change.

MILLER: Before 3TC was available, during your fellowship, what were the types of illnesses you were seeing?

MARSTON: The whole range: lots of pneumocystis, plenty of Kaposi's, plenty of CMV [cytomegalovirus] -- quite a lot of CMV retinitis.

MILLER: CMV retinitis?

MARSTON: Yes, a lot of tuberculosis, your friend or foe, whichever you want to say. A few very interesting things. We had a patient with Castleman's disease, which is maybe another manifestation of KSHV [Kaposi's sarcoma-associated herpesvirus], the virus that causes Kaposi's. Candida esophagitis, the whole works. I guess you could either think, oh my gosh, all we have is AIDS patients, or you could think, oh my gosh, we have -- today, it's Candida and tomorrow, it's CMV, and this day, it's pneumococcus.

MILLER: What were you treating them with? Do you remember some of the drugs that were available to you?

MARSTON: AZT was obviously the main first one. Bactrim prophylaxis was common by then, so that was something we did for everybody with low CD4 cell counts. I'm 00:22:00not sure I'll remember the exact year of introduction. The years I really remember are in '95 for 3TC, in '96 for the protease inhibitors, and in '97 for Efavirenz.

MILLER: Okay.

MARSTON: Indinavir was the first protease inhibitor that we really had access to. It was an incredibly effective set of drugs, but it was a handful of pills that people had to set their alarms (to take). It was almost like a meal with the number of pills, and they had to be taken with a fatty food or on an empty stomach. It was a very complex regimen, but the patients were pretty willing to try and do that. Not everybody, but across the board, I would say people were able to manage taking it, and we saw tremendous improvements clinically in a lot of patients.

MILLER: Now you're at the VA, an attending at the VA. What was the monitoring 00:23:00you were using at that time, as you were beginning to give out antiretroviral therapy?

MARSTON: We had CD4 cell counts. I don't remember from when exactly, but I think it was in '96 that viral loads became available. We had them sporadically available early on, and then they evolved into something that we did regularly. Then over the course of that time, we also started to get resistance information. We could get genotypes and phenotypes later in the '90s.

MILLER: What was it like for the patients at that time? What were some of the social and cultural factors that were going on as drugs are starting to be available?

MARSTON: With the VA population, there's a lot of concurrent social complexities with that group-- a lot of poverty and a lot of issues with mental health. Quite 00:24:00a few of our patients were homeless or struggled to find a place to live. A relatively common phenomenon in Atlanta is that a bisexual man isn't necessarily open with his female partner about the fact that he has male partners. That was a common scenario, to have somebody who got HIV but hadn't been able to disclose to his wife or female partner. (There were) lots of complex medical issues along with the HIV, so usually a problem list as long as your arm. (There was) a little bit of evolution over that time where it had been that HIV was the number one, the big thing, to now, HIV went down the list, and some of these other diseases became much more important.

I stayed on at that clinic, so I'm going to get memories mixed up. I think probably even after I came back from Kenya, I was going back to seeing patients there. The rule is always if the patient had HIV, they came to the HIV clinic regardless of what other medical problems they had. We would get somebody with an implanted defibrillator, and they would be my primary patient because they had HIV, even if their HIV was fully suppressed, fully controlled. Yet, they had these cardiac problems. That was a vestige of how in the early days nobody felt comfortable with the patients with HIV except for our group.

MILLER: Who were some of your colleagues at the VA and at your other clinic?

MARSTON: [Dr. David] Dave Rimland was probably the main one. He's retired now but was a giant in the HIV world. He had the foresight to really collect a lot 00:26:00of -- he got permission early on to collect standard information about all the patients in the clinic. So, we really had a good cohort in which we could do descriptive studies of how we were doing with respect to viral suppression or the prevalence of hepatitis C or whatever other issues came up. He and I ran the clinic, but one of the bonuses about being this close to CDC was that there were a lot of people who liked to continue to do some clinical work. Back in those days, my situation was I was an attending in the clinic, but people would come over from CDC and spend maybe a half a day a week. I probably won't remember everybody that did it, but like [Dr. Jonathan E.] Jon Kaplan, [Dr.] Anne Schuchat, [Dr.] Mary [L.] Kamb, [Dr.] Peter [D.] Drotman, lots and lots of people. We would have this --it was more so later, but a reciprocal relationship. Jon Kaplan was my boss when I came back to CDC in the late 2000s, but he was essentially like my fellow in the clinic. It was an interesting thing, and that was always fun. The CDC docs were pretty enthusiastic. The 00:27:00patients liked them a lot, and it meant that we were able to extend our reach and manage way more patients than we otherwise would have been able to with the resources we had.

MILLER: Anything else you reflect on in your clinical experience at that time?

MARSTON: Honestly, HIV was really the dominant thing. Of course, I would do a little bit of other infectious disease and inpatient work, and occasionally travel patients. Then as part of the fellowship, I did research. I ended up doing research back at CDC with [Dr. Thomas M.] Tom Shinnick and looking at tuberculosis. We never really got any great scientific output out of that, but the basic idea was we were trying to understand what genes were turned on during active infection as opposed to latent disease. We were using a luminescence detector protein to see whether a gene was turned on or not during active infection.

Throughout that whole time, I had pretty tight connections to CDC. I also had met and married [Dr. Laurence Slutsker] Larry. He was at CDC, so that was another way to stay in touch with CDC and then, of course, the proximity between Emory or the VA and CDC. We had a lot of collaboration, so even though I had technically left CDC, I hadn't really left CDC. People always like to assume I've been here since 1990. That's not even close to true, but I managed to maintain a relationship with a lot of people at CDC through that time.

MILLER: Then you and your family moved to Western Kenya. How did that all come about?

MARSTON: Larry and I definitely wanted to go someplace. Western Kenya seemed like the perfect situation for him, since he had done malaria work, a little bit 00:29:00of work on foodborne disease, and a little bit of work on HIV and TB. Basically, the field station did all of those things, so it was a perfect situation for him. For me, our children were very young. At that time, before we moved, I'd been pregnant or nursing for the four years before we left. I never saw Kisumu before we went; I just went sight unseen. It was actually --it was an easy decision, and it felt fine. I felt good about it. I had a rule that our younger daughter had to be one before we went, and we almost made that. She was just shy of her first birthday when we arrived.

We arrived in Kenya on September 11, 2001 -- well, we arrived in Nairobi on the 10th, but we arrived in Kisumu on the 11th. We left from Philadelphia because we stayed with my parents for a couple of weeks before we left. We drove up the New Jersey Turnpike to Newark, where we were flying from. I don't know if you've 00:30:00ever driven there, but about half of that drive you could see the World Trade Towers at that time. Then we took off from Newark. It was a cloudy day, but the Trade Towers were above the clouds. So, the very last thing that we saw of the United States was the top of the two World Trade Towers. I was on a plane with Emma and showing her -- because she was not quite three at the time.

Then we arrived in Nairobi. We spent the night in the hotel then went on to Kisumu. We didn't have phones; we didn't have internet. We had just arrived, so we had no information whatsoever. Our friend Kim Lindblade came to the door and said, something's happened, and explained what had happened. At that point, we didn't know if we would stay in Kenya or what would happen. We didn't have cash. We had nothing, but we went and put our cards in the ATM and got cash out. Although there was absolutely no travel for a couple of months after that, 00:31:00eventually things normalized and we stayed. I'd say that time for our family and for my career I think was the best ever. It got a little bit of a rocky start, but it turned out fine.

MILLER: This was in 2001, is that right? What was the atmosphere about HIV/AIDS in Kenya as you arrived?

MARSTON: You might remember this. I can't remember exactly, it was '99 or 2000, maybe, that one of the big HIV conferences had said, this is all well and good that we're making progress with treatment and with viral loads and things like that, but the world's HIV is not confined to the United States and Europe. It's primarily in Africa, and we should probably be doing something there. That idea was just starting to take shape.

I had actually planned to do malaria research when I went to Kenya. That was the arrangement we had made, but when we got there, that didn't seem like a good idea. The malaria research group was smaller than I had envisioned, and it would have put me too proximate to Larry as the field station director. There I was, an HIV clinician, and Kisumu was with an adult (HIV) prevalence of 25%. What made all the sense in the world was for me to do some work on HIV. Kevin De Cock was the country director at the time. He and I discussed it and really didn't take very long to make the decision that no, this is what I should be doing.

This is prior to PEPFAR. At the time, there was the LIFE [Leadership and Investment in Fighting an Epidemic] Initiative back at CDC, and there was some funding. It was primarily focused on testing and on prevention of mother-to-child transmission, but we had a small budget that allowed us to start 00:33:00thinking about care and treatment. It basically was enough to cover my salary and the salary of one person and a colleague in Nairobi named [Dr.] Doris [K.] Macharia. Then we had ten thousand dollars in discretionary funds, and what we decided to do is use it to buy cotrimoxazole.

There were several situations in which people were being identified as having HIV, and the whole point of testing was, it was being promoted as oh, find out you're negative and stay negative. There wasn't really much to say to somebody who turned out to be positive. Obviously, in Kisumu with a 25% prevalence, many of the people who were tested were positive. There was an enormous need to offer something. Even though antiretrovirals weren't in the cards at the time, it seemed like we should do something for those people. We were able to set up some clinical services and essentially offer Co-trimoxazole, which made a tremendous 00:34:00difference in the health of people. It also let us get started establishing clinical services, and then we could get antiretrovirals through a few channels.

MILLER: Before we go into the treatment, can you tell us a little bit about -- so 25% in Kisumu. Nyanza Province had one of the higher rates of HIV in Kenya. What were some of the factors that were driving this raging epidemic in Kenya at that time?

MARSTON: The dominant ethnic group in Nyanza Province is the Luo people. Polygamy is common there, and also there's quite a complex set of beliefs that associates sex with outcomes of various things. For example, if you want to have 00:35:00good luck fishing, there's an understanding that you should have sex before you go out fishing, and if you -- There were a lot of things like that. If somebody's husband died, then there was a practice where the brother of the husband would inherit the wife, and that had sexual connotations. There were quite a few practices that led to having people having interaction with multiple partners. So, the rate there was 25%, even though the national rate was more like 7%, but it was high in Kisumu.

MILLER: Before you got into treatment, were there various prevention activities? You mentioned prevention of mother-to-child (transmission). Was antenatal screening a treatment regimen used in a large way at that time when you got there?

MARSTON: In those days, PMTCT [Prevention of Mother-to-Child Transmission] was primarily just with single-dose nevirapine, and I was involved to some extent. This all gets complex, but we wanted to try and extend what we could offer, treatment-wise. First of all, PMTCT was one example where you'd find somebody who was positive and you said, okay, you can give nevirapine and reduce the risk that they would transmit HIV to their infant, but then what can you offer the mother? That was one source of patients for this clinic we started with the Co-trimoxazole. It also turned out to be one of the first ways we got any treatment availability at all. There was a grant that was available from Columbia University's Mailman School of Public Health, and it was essentially to offer treatment to women who were identified in the context of PMTCT. I got involved in that. We wrote the grant and got funding so we could provide some 00:37:00treatment. That was one source of antiretrovirals before PEPFAR got started.

MILLER: Were those complete three-drug regimens?

MARSTON: Yes. I don't even know if I can remember. I think it would have been primarily stavudine, 3TC, and nevirapine. That would be the most common regimen.

MILLER: Were those complex regimens to take? How was retention in those early years of using three drugs?

MARSTON: People did well with it. Obviously, not every patient took every pill. The regimens were usually a couple of pills twice a day. There was a lot of concern in the general world that, oh, people wouldn't be able to take these drugs living in Africa. I think that turned out to be a wrong assumption. I think people did at least as well taking the drugs in Africa as they did 00:38:00anyplace else. It wasn't necessarily the very best regimen that was available in the world at the time, but it was a combination of manageable and affordable, relatively speaking. Obviously, these were very expensive treatments compared to the usual therapies that are available in Africa. Stavudine was a couple dollars a month, and that was a drug that we could get and was available.

MILLER: Were you required to use the U.S.-approved drugs at that point?

MARSTON: It depended on the context. We did one activity in Nairobi that was really an effort to evaluate whether you could give antiretroviral therapy in an African context. That was in the Kibera slum in Nairobi, working with Doris, who I mentioned before. For that one, we had to use U.S.-approved drugs. For the Columbia program, they provided the drugs, and some were and some weren't 00:39:00necessarily the U.S.-approved. We did end up --it's very complicated. When Kenya was providing some drugs, those most of the time were from Indian manufacturers.

MILLER: Do you remember how you were monitoring the patients in those very early years, how often and what laboratory availability you had?

MARSTON: We had ability to do CD4 cell counts locally pretty early on.

MILLER: Using an FACS [fluorescence-activated cell sorter] counter?

MARSTON: I can't remember exactly when we got the FACS counter. We ended up with bunches and bunches of FACS count machines, but I think even early on for the -- there was the capacity to do CD4 cell testing in Nairobi. For this program we were doing in Nairobi, that was this evaluation of whether you could effectively 00:40:00give antiretroviral drugs in an African context. We did CD4 counts as part of the routine monitoring of the patients. Then separate from that, we sent blood back to the U.S. for viral load testing, not as clinical monitoring but as an evaluation of the effectiveness of the project.

MILLER: Was this in the Kibera slum? Was it an observational study?

MARSTON: Yes, whether to call it a study or not was a big point of debate. I can picture-- I'm not really sure who all was around the room, but it was Doris and me on one end of the phone and then what sounded like a conference table full of people in Atlanta, to try and negotiate whether this plan to provide antiretroviral therapy to people with HIV was a program or a study. Eventually, we got it described as a program with an evaluation component, which I think is just right. People gave consent because they were getting blood taken for the 00:41:00viral load monitoring that wasn't going to be part of their own monitoring. It was us trying to see if the program worked.

MILLER: What regimen was used for this one? Was this a similar regimen to what you were using in Kisumu or a different approach?

MARSTON: I think it was either -- I don't even remember, but I think probably stavudine, 3TC, and nevirapine or AZT, 3TC, and nevirapine.

MILLER: But everyone was on the exact same regimen? Is that right?

MARSTON: Essentially, yes. That was one of the big features that made it different. It was standardized regimens and then reduced frequency of monitoring compared to what was regularly done in the U.S., particularly -- not so much with the CD4 cell counts, but with things like complete blood counts or blood chemistries and things like that. My own experience was, we did all that monitoring, but it rarely changed what we did with the patient. Even if there were something that we found with that monitoring, it would almost never be that 00:42:00we would stop the drugs. Anyway, we felt better giving the drugs without the monitoring than not giving the drugs because we couldn't do the monitoring.

MILLER: You couldn't do the monitoring because it was too expensive or too time-consuming for the patient or laboratory?

MARSTON: It was felt to be not feasible from a scale-up standpoint. In this focused effort we could have but given the numbers of people and the resources available in Africa, the thinking was that we would be better taking whatever limited resources there were, more so buying drugs and less so buying expensive laboratory monitoring. It was really a resource distribution question.

MILLER: Would the monitoring have been more likely every six months?

MARSTON: Yes, whereas we might, even in the clinic and the VA --

MILLER: In the U.S., it might have been every three months?

MARSTON: Or even more frequent, especially at initiation, yes. It was a hard thing to sell, because one of the key things about any public health context is that it's hardly ever comfortable to say, we'd like to give you this not-quite-as-good effort to control HIV as what we have in the U.S. I felt pretty strongly at the time that what we did in the U.S. wasn't necessarily better. Yes, we did more frequent monitoring, and yes, we tailored the antiretrovirals to the individual patient, but I'm not sure it was a good idea. People would end up saying, "Well, I don't really like the pink pill," or "I'd like a smaller pill," or "I'd like one that's diamond shaped." You ended up making changes for silly reasons. Even from an individual perspective, if you had a standard approach, I didn't think we were giving them the "B" treatment. I felt like we were providing "A" level treatment, but --

MILLER: Your colleague was Doris Macharia. She's a Kenyan.

MARSTON: Yes.

MILLER: Did you need to go through any Kenyan institutional review boards?

MARSTON: Yes.

MILLER: Or KEMRI [Kenya Medical Research Institute]? If you can describe --

MARSTON: It was KEMRI, yes.

MILLER: (Can you say a) little bit about what was the Kenyan attitude towards this?

MARSTON: That whole -- the point we were just talking about was a big deal. It was a multipage protocol, but about six pages of it was, here's why there's really no need to do more frequent blood monitoring, and here's why it's okay to use standard regimens. I would try and explain my perspective about that to our colleagues. Some people were totally fine with it, and some people were like no, we want whatever you would do in the US. I think it was in 2002 that WHO [World Health Organization] came out with their first Guidelines for Antiretroviral Therapy. WHO said reduce frequency (of) monitoring, and (use) standard regimens. That made my life much easier because now, instead of six pages of defense of 00:45:00this idea, I simply put "and in accordance with WHO's recommendations for standardized regimens and reduced frequency of monitoring." I think it was very telling about the impact or gravitas of a WHO recommendation in that context. People, once they saw that WHO had recommended it and it wasn't just this American doctor trying to say that the lesser thing was okay for Kenya, it became very easy from that standpoint.

MILLER: Uganda was doing a study looking at clinical monitoring versus more laboratory-based monitoring, but I don't remember the timing. Was that before or during your decision on this particular project?

MARSTON: It was about concurrent. I think there's -- [Dr. Jonathan H. Mermin] Jono will tell you, but it was considered a study because there was randomization to the different arms. With ours, everybody got the same treatment, but it was right about the same time. We had a lot of shared experiences.

MILLER: So, the data weren't there yet to confirm it.

MARSTON: Right.

MILLER: That must have been very exciting.

MARSTON: It was, and --

MILLER: How did it go in terms of the clinicians, the Kenyan clinicians, and whatever outpatient facilities were available in Kibera slum? How was healthcare delivered in that setting?

MARSTON: This was a relatively small program. I don't remember exactly how many patients, but maybe a hundred or a couple hundred. We worked in one clinic in Kibera. We basically had control and some resources to up the level of care that was available. I would say -- I don't know about you, but when I learned antiretrovirals, I learned AZT and then maybe stavudine came in. I learned that and then 3TC, like basically add one, add one. These guys had to learn the rack of them at once, but luckily, we kept it a little bit limited about what they 00:47:00had to learn. They were terrifically able to learn, and I think the quality of care that was provided was good.

People were skeptical. Some patients had heard about antiretroviral therapy and were anxious to receive it. Some people were afraid of it. There were people, especially some people that sold herbs in the area that they said were good for HIV, that felt that it would be helpful to them to spread some rumors that those drugs would be bad for you. That way, more people would come to them for the herbs. We had to do some qualitative work and some social behavioral communication things to help people understand that we were sincere and that these were good treatments.

We got those viral load results back after we did the monitoring for a period of time, and 85% of the patients were suppressed. We were talking about being emotional or not, but when that came back, against everybody's expectations, to have 85% - that was substantially higher than we were able to achieve in the 00:48:00very early days at the VA. I think the differences included --in the early days in the VA, we had all these people that had been on AZT and then AZT/3TC and then triple therapy, whereas the group in Kenya started with triple therapy. I think medically, it's not surprising that we were able to achieve high suppression. It dispelled, basically, people's concerns about adherence to therapy and whether it could be done in this context. It was pretty exciting to get those results back. Doris and I were both pretty excited.

MILLER: Did that program continue when you stopped the implementation program, or what happened to that?

MARSTON: It eventually evolved into a more regular treatment program, because 00:49:00scale-up in general started to happen around that time. I had gotten a grant from Columbia for the work in Kisumu. The main point there was that they only supported treatment for the women who had been identified while they were pregnant, but I basically made it a condition. When the staff from the program came to visit, I said, we can't just treat pregnant women. There are so many people here who are sick. We need to use some of these resources for others. They were generous about allowing those resources to overflow so that we could staff the clinic. They didn't give drugs for the other patients, but the doctor and the clinical officers were able to see the other patients as well. That grant from Columbia supported not just the women who had been identified in pregnancy but was a critical part of the support for the rest of the clinic. Then we just started in little ways. A church or two would be willing to pay for drugs for somebody or a study or whatever, and we built up a small number of 00:50:00people that were on treatment. I think we started our first patients in very late 2002 and gradually built up a few throughout 2003.

Then PEPFAR was announced in 2003 and really got going at the end of 2003. Because we'd done some groundwork and there was great interest in seeing rapid results --the idea we had a clinic full of people that had been tested and counseled and were coming to care routinely, which, by the way, is weird in Africa. Most people don't do that. Most people come when they're sick, and that's it. The only group that really gets regular follow-up care is the infants getting immunization and then maybe patients getting TB therapy. This whole idea that you would go to a clinic for a chronic disease was basically a new paradigm. It took some getting used to, but we did have a clinic full of people that were just ready for drugs. When PEPFAR started, we were able to practically 00:51:00snap our fingers and get a whole bunch of people on treatment. That was the kind of result that people wanted to see, so we were well positioned to expand pretty quickly.

MILLER: Did you scale up to several clinics at that point, or were you still based in a few?

MARSTON: Way more than several. I essentially had two jobs. I was living in Kisumu and oversaw the treatment services in Nyanza Province. A third of the HIV in the country was in that province, but then also nationally. Doris was also working, so we both took the same approach in the areas where we were working. Essentially, we just went from clinic to clinic, saying, would you like to start an HIV -- this is once PEPFAR resources were available. Then we were in a situation where I could get as much money as I could spend, basically, to do this. You could go to a clinic and say, would you like to start an HIV clinic? 00:52:00They would say, we would like to but we don't have the resources and we don't know how. I'd say, that's okay, I have the resources and I know how. Working closely with the Ministry of Health colleagues, we could just look at that clinic, figure out who needed to be trained, what equipment they needed, and what supplies they needed. Then generally, the pattern would be, we'd start the clinic, enroll people, and start them on cotrimoxazole. If they'd been on cotrimoxazole for a couple of months, then they could start triple therapy, so we were -- I think the pattern now is test and start treatment right away, but at the time, we were still in this mode of worrying that people wouldn't adhere to therapy. We would get people on cotrimoxazole for a couple of months, and if they managed that, then they would start the triple therapy.

MILLER: Where were these clinics? Were these primary care clinics? Were they district hospital-level clinics?

MARSTON: Yes, I think there were, I want to say, twelve districts in Nyanza 00:53:00Province. I should be able to name them. We started by going to all the district hospitals and then all the health centers. We gave a little bit of extra focus to an area where CDC was doing research studies, which was Asembo Bay and basically Siaya District. The whole organizational structure in Kenya has changed now but (at the time) it was province and districts. I feel that while you can't offer treatment services like that to individuals who participate in research studies, it's perfectly ethical to prioritize those communities that contribute to research studies for receipt of services. No individual has to participate in research, but because the community has been participating in research that we were sponsoring at CDC, we went there first. It made sense anyway, because those were the highest rates of HIV (at) the district hospitals 00:54:00in Siaya and Bondo, and then --

MILLER: Was it hard for patients to get there? How did a patient get to the district hospital for the treatment? Were there transport issues?

MARSTON: Oh, there definitely were, and especially --for individuals that felt too stigmatized, then the transport became a bigger deal. They wouldn't necessarily feel comfortable going to an HIV clinic in the village where they lived, because almost everybody had a cousin that worked in the lab that would see them. I think the transport issues would get in the way of adherence when patients would try to do things like go to a different district hospital to get their treatment.

MILLER: How bad was the stigma of HIV at that time in Kenya?

MARSTON: I don't think you can really give a specific answer to that. It varied by individuals. Some patients were very willing to show up and come, and they 00:55:00would also be willing to speak publicly about their HIV. I think that helped a lot of other patients, but there were people that just would not. (There were) people that worked for CDC that we would pretty well assume had HIV but we couldn't manage to convince to get tested, or it took a lot of quiet work to get somebody to be willing to be tested. We lost some people at CDC because they -- even though the treatment was available-- we couldn't necessarily convince people to get tested and into treatment.

MILLER: Was it difficult for women or adolescent women, in terms of marriageability and so on? What was the feeling about that?

MARSTON: That's an interesting one. I think that was also variable. To be honest, a fairly common thing was, we would test a woman, find that she was positive, and tell the husband. The husband would be like, I don't want to know that, and that would be it. (The woman was) maybe still marriageable, but now 00:56:00there's a risk of transmission within the marriage. Others would disown the person when they knew, so it was a hard thing. I think the hardest part in some ways was that a woman couldn't agree to have a test without the agreement of her husband. If we were wanting to offer testing or treatment to a woman, you had to work with how to get the agreement of the spouse, because the husband was the decision maker. Eventually, we solved that by switching to an opt-out. We said, we're going to do testing unless you say otherwise. In that way, she could blame it on us. She could say, "The clinic did this. I couldn't make the decision to tell them no without you, so I've been tested."

Stigma was huge, but we were offering something that was so new and so needed that we didn't really have to worry about it except for the individual, meaning that we had plenty of patients that were coming. On any given day, we were busy, 00:57:00busy, busy. I remember the people back in PEPFAR headquarters were like, wow, if the national prevalence is 7%, you're going to have to test a hundred people to get seven, so how to meet these treatment goals? How are you going to test that -- you don't have to test that many people. It's all good if we test people, but all you have to do is hang up a sign that says we offer HIV services. Sick people will come, and you'll offer the services. We were basically picking the low-hanging fruit at that time and didn't have to worry about that individual and say, really, we'd like you to come. If we couldn't get that person to come right then, we had plenty of other people that needed to get the services.

MILLER: That must have been so exciting. What was the evolution of the community's experience of AIDS? You get there, and there's not much treatment 00:58:00going on. There must have been a lot of funerals. What was the atmosphere like in that way?

MARSTON: Funerals were the common activity. Most people went to a funeral every single weekend. The thriving business when I got to Kisumu was coffin making, and there were coffin makers on every corner. I think I said when we talked about this before, when we hired staff for studies, we had to over hire. We knew we were going to have a certain amount of attrition because there was illness and death in the study staff.

The thinking about antiretroviral therapy ranged from one extreme to another. Some people that were aware about it in the world (thought that) that we should have this in Kenya. Some people were very afraid of it. As people started to witness individuals who got the treatment getting better, it became much more accepted. I think the first group to really feel the impact, of course, were the individuals who got treatment, but then the healthcare workers. The healthcare 00:59:00workers at the provincial hospital at the time, within the hospital, 85%-90% of the hospitalized patients had HIV. The death rate was enormously high. The clinicians were like, what am I doing? If every patient dies, why am I a doctor? Why am I a clinical officer?

For me, you know, it was the second chance to see the impact of antiretroviral therapy. We went from a whole group of people that were sick and there was nothing to offer, to instant triple therapy. People just -- even with the cotrimoxazole, people got dramatically better, but with the triple therapy, they got dramatically, dramatically better. The clinicians would call and say, "Barb, Mister so and so is back, he's gained weight, he's much better," and that happened over and over again. I think the morale for the healthcare workers was the first thing that came up. Then almost everybody had family members with HIV. If you stretched it out far enough, almost everybody had a family member with 01:00:00HIV who'd gotten treatment and gotten better. It didn't take very long before people really appreciated and understood and you could -- I don't know, you could test -- I always liked to test with the taxi drivers, "Do you know about HIV? Do you know about treatment?" Early on, no, no, no, but over the time (I was) there, they became very aware. They always had a family member who'd been treated, or they would say, "Oh yes, we used to take people to funerals all the time. Now there are no more funerals." Yes, it was a big and palpable change in the rate of death and at every level. In individuals that got better and, in the clinic, and then in the community, you could see the impact.

MILLER: Now, you were working for CDC and were reporting to Kevin De Cock in Nairobi and then back in Atlanta. (You were) part of the PEPFAR staff in a 01:01:00distant way?

MARSTON: Yes, it was actually complicated. Technically, I was working for the VA. We had an interagency agreement that the VA paid the salary so CDC would hire me. I think once PEPFAR came in, I was under Kevin initially. As PEPFAR expanded, (I was) essentially under [Dr.] Tedd [V.] Ellerbrock's team [HIV Treatment Team, Division of Global HIV/AIDS, CDC].

MILLER: Can you comment a little bit about CDC's role in all of this? You mentioned it by the side, but can you dissect a little bit about what CDC was doing there and how CDC worked in-country, and what advantage it was to being a part of CDC while you were there?

MARSTON: It was mixed, honestly. Our big thing, of course, is to work closely 01:02:00with Ministries of Health. That was certainly the case in Nyanza Province. I very sincerely tried to make everything we did be a part of the Ministry of Health's efforts. Even the early clinic where it was supported by the Columbia resources was -- it wasn't my clinic and it wasn't the Columbia clinic, it was the provincial hospital clinic with these resources.

I think I mentioned a little bit this woman [Lennah Nyabiage] that I worked with in Nyanza Province. She was very interested in supporting the HIV work, so much so that she volunteered during her time off to come. Initially, she did some work on the TB program, but we got to know each other and she eventually became the antiretroviral treatment coordinator for Nyanza Province. We were quite a team. Of course, I had all the dollars, and she had the title. We would go together to a clinic and work it out. Then I was able to say, yes, we can 01:03:00support this and this, and she then could say to the clinic, "I've identified these people that will get trained. We will bring you cots." The Ministry of Health they were all Ministry clinics that we worked -- not a hundred percent, but almost all Ministry clinics. At the time, I mentioned PEPFAR really wanted to see these rapid results. If another partner like a funded NGO [nongovernmental organization] or whatever could see, oh, these Ministry of Health clinics were doing very well, they would like to jump in and be the partner. I'd say, "No, no, I'm already the partner," but they would say, "We can't see. It doesn't say NGO X on the sign here, it says Ministry of Health." I'd say, that's right, that's how we work." It's a little bit of a double-edged sword.

I think, [Dr. William H.] Bill Foege makes a point that as long as you do the work right, the appreciation will follow. I'm afraid I don't a hundred percent agree with him on that. I feel like we lost a little bit in terms of being so 01:04:00careful to credit the Ministry of Health, which I personally believe in completely. I think the problem in that equation is the people who want to ask, what have you done? I say, okay, I was behind that. It's easy for people to say, maybe it was just the Ministry of Health doing it on their own, and it wasn't. I was working very hard to make this a reality.

Early on -- it's no longer true, but early on, I was the one with the knowledge, so I could do the training and figuring out how. At this point, the clinicians in Nyanza Province have surpassed me by log scales with respect to the numbers of patients that they've seen, but early, it was helpful to have substantial clinical experience. Anyway, you can overdo it, is what I'm trying to say with respect to crediting the Ministry.

As PEPFAR scaled up, we worked closely with USAID [US Agency for International Development], and it was complicated and not always good. I had a wonderful 01:05:00colleague on the USAID side who was doing the care and treatment stuff. He and I worked together on some great -- we had some difficult stuff and then some great stuff. One of the difficult things was, early, they had some partners that simply weren't performing. He was like, "Barb, you have to give them a break. They're not used to being judged on what they get done." I was like, "Well, what are they judged on?" It had been until that time the ability to spend money. That's fine, but why don't we at least -- Anyway, over time, that's one of the great things PEPFAR has done, I think, is shifted the focus of our development work to outcomes rather than just spending money, but that was the culture at the time.

[Dr.] John [Wasonga] and I also -- you know, where do you get drugs from PEPFAR, and that was a big issue. Eventually, there was this whole supply-chain management project, but prior to that, how we did it in Kenya was to get the 01:06:00drugs through something called the Mission for Essential Drugs and Supplies. It's a fantastic organization that supplied drugs to the mission hospitals. I remember John and I, we needed to --

MILLER: These were the faith-based mission hospitals?

MARSTON: Yes, exactly. We needed a contract signed, and MEDS, the Mission for Essential Drugs and Supplies, the people who were on the board were all these archbishops. I don't quite know what happened, because John -- it was a USAID contract, but anyway, we got to the point where we needed the contract signed. We needed six signatures from archbishops in a period of about twenty-four hours. John and I went off on the great bishop hunt. I got three, he got three, and mine were all in Western Kenya. Luckily, two of mine were Anglican, because it turned out to be a lot easier to find a bishop if they're married. You can find their wife, and then they know where the bishop is. A CDC driver and me, driving all over: hello, hello --have you seen him? do you know where--? -- where's his wife? -- and eventually, we got the contract signed. Anyway, it was 01:07:00fun working with John on that and seeing the national scale--up. We not really officially but eventually took different regions and different partners and were able to make things go pretty fast in Kenya. I'm not sure it was the best approach. I honestly think, you know, if you go a little more slowly and get a little more standardized, that's probably better in some ways.

I think for PEPFAR, having a country that was going fast like Kenya was helpful in securing additional resources. We ended up with a bit of a mish-mosh of people with different programs and doing it in different ways, because there was already such a broad range of NGO partners in Kenya. Other countries, like Tanzania, I think did it much more -- everybody's going to do it the same way, and I think if you drew a graph, Kenya would go up faster, but Tanzania over a 01:08:00certain amount of time would get to the same point. That kind of standardized approach maybe would work better in the long run, but we were able to get a lot done fast. I think that was helpful for returns for the whole PEPFAR program.

MILLER: Do you think it controlled the epidemic more quickly, by virtue of the rapid scale-up?

MARSTON: I'm not sure. I don't even know exactly what the situation is in Kenya right now. I think that they're at a million and some on therapy, which is crazy. For me, I think I told you this before, too, but at that early clinic we had in Kisumu, we had three hundred and something people on treatment before PEPFAR started. We had gotten a call -- [Dr.] Elizabeth Marum got a call from somebody from NIH [National Institutes of Health], saying, we'd like to help you start a clinic. She said I think we already have some people on treatment. Let me call Barb and find out. She called me, and she's on the phone to both of them. She says, yes, they have three hundred and some people on treatment. The NIH person was like, oh my gosh, that's some huge number. The idea that three hundred people is a lot of people is ludicrous at this point, given the numbers, 01:09:00and even --I felt like we were going fast, but when I left Kenya, we were at about sixty-five thousand. That's peanuts compared to what has been achieved since that time. It was, the slope of the curve was steep and it was -- even that was enough to make that palpable difference, really, across the country in terms of funeral frequency.

MILLER: Any other reflections on the experience in Kenya that come to mind?

MARSTON: It was definitely the best job I've ever had. The idea that there's something you're very comfortable doing and you have the resources to do it, 01:10:00that's a pretty amazing situation to be in. It was also that Kenya's a beautiful country, and we had help in the house. Even though we were working hard, hard, hard, it was very gratifying work, and we didn't have to spend time cleaning the bathrooms and whatever and so --

MILLER: How did your family do? How did the girls do?

MARSTON: There was a little tiny school in Kisumu. Things have all changed since the post-election violence in 2007 and 2008, but there was a beautiful school with trees with weaverbirds. They both went there and learned everything we could have -- we expected we'd have to come back sooner for Emma to start school, but she was doing fine. She learned to read and everything, so it was a good situation for them. Then we'd go -- I'd be in the hospital in the daytime and then at night, (we'd) go down to the shores of Lake Victoria, and there 01:11:00would be hippos and gin and tonics. (We would) travel to the Maasai Mara [National Reserve] and see cheetahs and leopards and whatever, so it was a pretty spectacular opportunity for our family, I think.

MILLER: You've done so many things, but I thought maybe we would conclude by talking a little bit about your experience as the lead of the Heavily Affected Countries team and the International Task Force Emergency Response to the Ebola Epidemic in West Africa, where CDC played quite a role. Can you tell us a little bit about what your role was in that position and briefly describe the epidemic?

MARSTON: I always smile when people ask me that, because I was down in Haiti and [Dr.] Mark Anderson called and said, can you do a rotation in the EOC? I just said yes, without asking questions.

MILLER: EOC being the Emergency Operations Center?

MARSTON: The Emergency Operations Center. I got there, and I said, okay, what's my job? They said, you're going to lead the Heavily Affected Countries team on the International Task Force. I go, okay, who is that? They go, that's your first problem. Essentially what had happened was the Viral Special Pathogens people had deployed experts to the field for the initial part of the response, but, of course, people couldn't stay there forever. They now needed plans for who was going to replace them. Essentially, my initial job was to find people that would be willing to go out to each of these countries to coordinate CDC's efforts in the response. This is where twenty years of time at CDC really comes in handy. For example, I called Jono (Mermin) and said, Jono, would you like to do it? I may have talked to my husband to see if he wanted to take a lead role. I called Kevin [De Cock]. (I called) everybody I knew that had the appropriate experience to maybe coordinate a team.

MILLER: Do you want to say a line or two about the epidemic? Just in a few 01:13:00sentences, what was going on?

MARSTON: It started at the end of 2013, but it wasn't recognized until well into 2014. Basically, Ebola hadn't happened in West Africa before. It had been present for quite some time before the diagnosis was made. CDC had been involved in the initial response but hadn't necessarily been involved in what turned out to be a resurgence. We hadn't been invited back, and it was getting worse and worse and worse. The world was watching, and nobody really -- I think in general, people didn't take it as seriously as it needed to be taken. So it got worse and worse and worse, and eventually, CDC stepped up and took a big role in the response. The three countries declared disasters, and USAID came in with 01:14:00resources. CDC assisted with that whole response, but it was --

MILLER: It ended up being about eleven thousand cases.

MARSTON: Deaths. No, no: twenty-eight thousand cases and eleven thousand deaths. An absolutely enormous epidemic. Our contributions to the response early on were just figuring out what to do and predicting what was going to happen and tracking the epidemiology. I think we really shined-- or shone or whatever the word is-- toward the end of the response, when what you really have to do is find every last patient and make sure that every contact has been identified and that those contacts have been monitored. CDC had some very important inputs into seeing to the end of the epidemic in all three countries. It was -- at the time, it was the biggest response that CDC had ever done, and big by a landslide. (We were) finding the people to do the response and dealing with issues like making 01:15:00sure that we had plans for medical evacuation if somebody needed that, and then just coordinating the efforts in a situation where nobody had really done this before. (We were) figuring out what to do and how to communicate that back to the agency head and up to the White House. That was-- it was really just a coordination job from my perspective: find the people that would go and keep in touch with them as teams, maybe pass down some advice about what to do, not so much from me but from Ebola experts and others. Then gather the information from them to feed up here. I went for thirty days, but I ended up staying for two and something years. Then the work of assisting the countries with recovery of their public health capacity after the epidemic was something that was very familiar to me based on experience in Haiti. I ended up having that role until we were able to essentially work ourselves out of a job, and those countries ended up 01:16:00being handled more like all the countries were getting supported.

MILLER: Can you comment on CDC's role here in terms of what CDC brought to the table, to the experience?

MARSTON: For Ebola? Yes, again, I think, obviously, laboratory or standard stuff, so surveillance, (which was) not without its challenges. Surveillance is hard in a situation like that, but we did a lot of work to try and track the epidemic and offered a lot of laboratory testing. I think the field epi [epidemiology] was the thing that we brought that was the most important. Then after the epidemic, (we were) helping them to stand up their surveillance systems more generally, helping to build laboratory capacity, making sure that there were people trained in epidemiology. All three countries have field epidemiology training programs now. Tremendous progress.

We wrote a paper about it that explained that, even though that kind of capacity-building generally speaking takes years, you can do it faster under 01:17:00some circumstances, and this was one. Maybe a couple of the reasons are that one of the things you need to make public health progress is you have to have stakeholders who believe that it's important, not just the people in the Ministry of Health, but the President of the country or whatever. You want the President to understand the importance of public health. An Ebola epidemic will do that, and so we had everybody on board. We had developed relationships, very close relationships with our counterparts in the Ministries of Health. We were, I think, very well positioned to support that kind of rapid expansion of surveillance and laboratory capacity. It was a pretty exciting time. Prior to this epidemic, CDC's presence in West Africa had been pretty limited. Not zero: there was the field station in Côte d'Ivoire, and we had activities in Senegal and Nigeria, but these three countries in particular didn't have a ton of CDC presence. We do now. I think that's good.

MILLER: Parallels have been drawn between response to the Ebola epidemic and the AIDS. Do you want to comment on that at all? Did you draw on some of your experience in addressing AIDS in the early years?

MARSTON: Sure. I think Ebola felt to me like the HIV epidemic on fast-forward. There was a lot of the same things, like (it) couldn't really be and then oh, it is. Then we need to do something, right, but (at first, we were) a little bit slow to it and then an aggressive response. (It was) very stigmatizing for the people that had Ebola. I think maybe the closest parallels beyond that fast-forward thing, we did some work trying to test -- especially in the course of this epidemic, that Ebola can persist in the semen of male survivors and maybe in some other places in survivors. That meant that - one of the things 01:19:00that CDC did was help set up some testing programs for survivors. You're asking somebody who'd survived Ebola to come in and provide a semen sample to be tested for Ebola and then to give back the results. That whole setting was very similar to HIV testing and counseling. To be honest, it wasn't something I was super involved in, but you could definitely see the parallels. We ended up tapping into some people with really strong experience in the HIV counseling and testing realm to do that kind of testing and counseling for the Ebola survivors.

I think (there were parallels) in terms of its devastation and its ability to highlight the stark disparities between the well-resourced world and the under-resourced world. It felt similar in many ways to me. I think people are amazed or surprised to find out (for example), let's go train all the people in 01:20:00Senegal; they've had one case of Ebola. We can train them but, by the way, they don't have gloves. You're going to have to start with getting some gloves there, too, and people just can't -- I think it was hard for people to really picture what the circumstances were. These were very poor countries, and the impact of Ebola was pretty stunning.

MILLER: Thank you very much. Any parting reflections? This has been terrific. Thank you so much.

MARSTON: Thank you.

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