Global Health Chronicles

Dr. Barbara Marston

David J. Sencer CDC Museum, Global Health Chronicles

 

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Dr. Barbara J. Marston

Q: Hello, this is Sam Robson here with Dr. Barb Marston. Today is July 11th, 2016, and we're in the CDC [Centers for Disease Control and Prevention] audio recording studio at the Roybal Campus in Atlanta, Georgia. I'm here talking with Barb about her part in CDC's Ebola response to the 2014 to 2016 epidemic. Thank you so much, Dr. Marston, for being here. Can I start off just by asking, can you pronounce your full name for me and tell me your current position with CDC?

MARSTON: That's actually a hard thing for me, pronouncing my name, but Barbara Marston. My current position is lead of something we call the Ebola Affected Countries Office. It's a new office that's been stood up since the outbreak to basically carry on the work that was done during the response in the three countries and move over beyond the response to the epidemic into some of the recovery and global health security work there.

Q: Okay, awesome. Can you tell me when and where you were born?

MARSTON: I don't know that either. I was either born in Cambridge or Boston, 1:00Massachusetts--I'm not sure where the line is between the two--but in 1960, so a good while ago.

Q: Did you grow up in the same area?

MARSTON: No, I lived there for about a year and a half and then grew up outside of Philadelphia for most of my life.

Q: What was it like growing up outside of Philadelphia?

MARSTON: Very easy, I would say. Suburban. I have a nice, intact family. My dad worked for GE [General Electric] and then taught at Villanova [University], and my mom was a schoolteacher, and we had a pretty straightforward, easy life. Go to school, good schools.

Q: And you mentioned before we started talking that you have at least one sister?

MARSTON: Three sisters.

Q: Three sisters.

MARSTON: I'm second of four girls.

Q: What kinds of things did you get interested in growing up, like up through high school?

MARSTON: Frogs. I've always been a big fan of frogs and toads, amphibians, 2:00reptiles in general, but I think from a pretty young age I wanted to be a doctor, although not quite what I ended up doing. I had visions of being an emergency room physician from a pretty young age, and I did end up going to medical school, but then I didn't end up going into emergency medicine. I went into internal medicine. I went from there.

Q: Emergencies of much broader, I guess, means.

MARSTON: Sure. I mean, for me. I did internal medicine and then a residency in that, then came to CDC for EIS [Epidemic Intelligence Service], then went back into clinical medicine and specialized in infectious diseases. My clinical path was mostly infectious disease treatment, largely HIV [human immunodeficiency virus]. But then in 2001 my husband got a job in Kenya, and I went as what we 3:00call the trailing spouse. I was going to work with him on malaria research, but when I got there I realized how small the research group was, and it was basically too close of a relationship to be comfortable. It was also in the beginning of the--it was 2001, and it was right at the time when the world had decided that HIV care could potentially be made available in places that needed it beyond the United States and Europe, which is really the only place it had been made available to that time. The world was coming right around to that. PEPFAR [President's Emergency Plan for AIDS Relief] hadn't started yet. That's the program for US government support of HIV treatment. But we had some limited funding to start some treatment programs, and so I ended up taking on the coordination of the HIV care and treatment programs in Kenya and got back in with CDC at that point.

Q: Right. Can I back us up for just a second?

MARSTON: Sure.

Q: I think I've read that you were in the respiratory diseases branch when you 4:00were in EIS. Is that accurate?

MARSTON: It's half accurate. Very few EIS officers switch positions during their time here, but I started out in the International Health Program Office. It's kind of a complicated story, and I don't know if I know all the ins and outs of it, but basically I initially matched with the International Health Program Office, even though my top choice had been with some of the groups that were at the time the Division of Bacterial and Mycotic Diseases, DBMD. We've been through a few reorganizations since then. And partway through my EIS time one of those positions was vacated, and so they supported me moving from IHPO [International Health Program Office] to the open position in respiratory diseases, which is unusual. But that's what I did, so part international and part in respiratory diseases.

Q: Right on. Are there some responses, outbreaks that you were involved in 5:00responding to that kind of stand out when you look back?

MARSTON: As an EIS officer I actually didn't do that much in the way of outbreak response. I did one Legionella outbreak response in Los Angeles. Mostly I did things that were a little more long-term. So a big pneumonia study in Ohio, and as a result was to every hospital in both Akron and Columbus, Ohio. Not many people can say that, but I've been in all--at the time there were fifteen hospitals between those two cities, and I've been to all of them. So some slower-paced stuff, some surveillance work in the big pneumonia study. The other outbreak that I did was [really] interesting. It was Buruli ulcer, which is a disease caused by one of the bacteria in the same general family as tuberculosis, but it causes ulcers in kids and leaves terrible scars. There was a problem in Ivory Coast, and Kevin [M.] De Cock was the country director in Ivory Coast at the time, and people asked him, "With HIV, are you seeing a lot 6:00of these nontuberculous mycobacteria?" and he said, "No, but interestingly we are seeing this." That led to an outbreak investigation, and I got to respond to that, which was probably most important to me for getting to know Kevin and not so much for the Buruli ulcer investigation, which we did. I don't know how much I added to the world's knowledge of that, but I did get to know Kevin at that time.

Q: What was Kevin like back then?

MARSTON: He's like he is now. He's a little bit ageless. I think even at that point he was really one of the people that had very good vision for what an overseas country office should or could be, and the possibilities for bringing scientific work or even program work to places that were under-resourced. The field station in Abidjan was mostly research-focused at that time--that was 7:00Projet Retro-CI [Retrovirus-Cote d'Ivoire]--but amazing work came out of that field station, and it was fun to see and fun to get a taste of what international work was like.

Q: So out of EIS you went down the infectious disease route, right?

MARSTON: Mm-hmm.

Q: Okay. What prompted that?

MARSTON: I guess I wasn't quite ready to give up seeing patients. I like to keep all the doors open, and I missed seeing patients at that point and wanted to go back and see patients, I think is the main thing.

Q: Gotcha. I wanted to ask also, you mentioned Kevin De Cock. Were there others up through that point, when you were doing an infectious disease fellowship, that you'd say had a big influence on you or that you would call a mentor maybe?

MARSTON: Sure. I mean, my main EIS mentor ended up being Rob [Robert F.] 8:00Breiman, and I have crossed paths with him multiple times since then in my time. He'd be embarrassed to say one of the things he taught me I think was to really do more than you have money to do, meaning, you know, this pneumonia study that I mentioned, we had a certain budget for it. I think any sane person would say that what we attempted to do with that budget was way more than one could reasonably do with that budget, but then you end up doing more. I actually think that was something to learn. Rob always has one of my favorite quotes from the CDC, which is when he first came here--I think the quote was something like, "They pay you to do this?" Which is really true. The boring parts are boring, but the fun parts of public health are really amazing when you find yourself on a plane flying to somewhere, or out in a community meeting people in rural Kenya, and you think, this is a remarkable experience, and not only that, I get 9:00a paycheck for it. That's words to live by.

Q: Okay. Not that--as we'll find out--hard work isn't involved. [laughs]

MARSTON: No, right. You know my sister, one of these sisters, when I was in residency, which is a time in your life when you're working ninety-hour work weeks, and she was working forty hours a week but at a job she didn't particularly enjoy. She asked me, she said, "I just don't know how you do it." I go, "The difference is I like my job," and that makes it easier to do the long hours. I think it's a good thing if you can find something you like to do. If you have to do a lot of it, it's not so bad.

Q: Yeah. Then, let's see, I think we've traced your career up now through maybe HIV, global HIV work. Shall we talk about Haiti?

MARSTON: Sure. I ended up doing HIV work in Kenya and supporting CDC's efforts 10:00to develop HIV care and treatment programs there. Then when I came back I worked with the Global AIDS [acquired immune deficiency syndrome] Program, kind of supporting--but from headquarters--the same sorts of things. Then the first time I participated in a big CDC emergency response was to the cholera epidemic in Haiti, so that followed--the earthquake occurred in 2010, and then the cholera response was later that year. As part of that I got to know the team in Haiti. I think I was ready for a change and ended up shifting over to work with that office. It was actually kind of a change and kind of more of the same.

I think what I really wanted out of the shift to Haiti was an opportunity to really focus on one country and get to know the people there. When I was working in Kenya I really developed relationships with the people at the Ministry of Health and the locally employed staff. When you come back to headquarters, you do a little bit of work in a lot of different countries, and I appreciated the 11:00idea of really being more in depth in one and the relationships there. But for family reasons we weren't ready to go back overseas. So Haiti was kind of a way of finding that circumstance, being able to be stationed in Atlanta but work so intensely in a country that you have those relationships with the people there. It was the closest thing to being in an overseas office without actually being in an overseas office, especially because the travel to Haiti is so straightforward. You can leave in the morning and be there at lunchtime.

The scene was really quite familiar to me, very similar in some ways to Kenya. When I first worked in that office I was focused pretty heavily on HIV and TB [tuberculosis] work, so it was in some ways a change, in some ways not so much a change. But then we also had very substantial funding to support public health programming following the earthquake, and that variety was really intriguing, too. Eventually I took over the leadership of that office, which meant 12:00overseeing programs across a wide variety of things, so the HIV and TB, for sure, but also the efforts to eliminate lymphatic filariasis, some malaria work, some safe water work, maternal health work. It's really fun to see that variety.

Q: You mentioned it was not right at the juncture of the earthquake in 2010, but during the cholera outbreak when you got involved, is that right?

MARSTON: Yes.

Q: Did much of your work--I know you mentioned clean water--involve that?

MARSTON: Well, the way that worked is after the earthquake, that's when the funding was made available, some funding was made available to stand up basically a Health Systems Recovery Office. It's a complicated story, but there was a lot of money put aside for Haiti to cover both public health needs and any emergency medical care needs. So the initial efforts to do public health had been started, but then when the cholera epidemic was recognized, and there was 13:00still this additional funding that was available, CDC said, well, how about if we use some of that funding for the cholera response? And that was approved. Eventually very little of the funds that had been set aside for the emergency medical treatment were needed, and so they were almost entirely used for the public health response, and that allowed us to do that very broad program of activities. A very unusual situation at CDC to have that much funding focused on one specific country. I forget where we were going with that.

Q: Oh, no, I was just asking about the origin of the cholera thing.

MARSTON: Yeah, so I got involved at the time of cholera, but that was the start of expanding the funding, sort of asking for additional funding to use for these broader health initiatives.

Q: Right. Did you feel like by the time you left there was a much more sustained system, or how did things look by the time you were done in Haiti?

MARSTON: Sustained is probably the last word I would use.

14:00

Q: Oh, I'm sorry.

MARSTON: It was a dramatically improved system, but not necessarily with--the sustainability was the big problem. So this was a big bolus of funding, and we were able to do a tremendous amount, and I like to think that some of it was sustainable, but some of it was shorter term, which doesn't make it bad. If you can make an improvement for a period of time, it's still an improvement, and you still save lives, and that's helpful. It would have been ideal if there had been a source, and who knows, maybe there will be, but for sustained funding for some of these activities in Haiti. I think they're all valuable, but probably the one that I would treasure the most is the Field Epidemiology Training Program. [When you] look at that, that might be the most sustainable one. During the time I was still involved in Haiti, chikungunya hit Haiti, and you could really see some of the FETP trainees taking over the leadership of the response to that. I think that stood them well with respect to getting Haiti ready for possibilities like 15:00Ebola or for the reality of Zika that's come. You see the field epidemiology graduates playing big roles. And they're not--sustainability, you can think about it in a lot of different ways. In Haiti hardly anything is sustainable unless you can find money for it, because the country is so poor. But as long as there's some continued funding, then the field epidemiology trainees can really make a big impact, and I think that's a sort of sustainability that you see there.

Q: Yeah, like the human infrastructure. Absolutely.

MARSTON: Right. The other things, some of them hopefully will be sustainable. For example, the efforts to eliminate lymphatic filariasis might actually work, and so if we can eliminate lymphatic filariasis, that's sustainable by itself. Some of the other programs, sadly, the impact might be more short term. We had 16:00some inputs that led to dramatic improvements in the rates of measles vaccination, but every year there's another group of babies, and they need to be vaccinated, too. Although the measles coverage rates went up, [for a while] they started to fall as the resources became more limited.

Q: You had mentioned also wanting to be focused in one country and also developing relationships with the people in that country. What are some relationships that you developed in Haiti that you look back on and kind of stand out to you?

MARSTON: Probably the most treasured ones would be with some of the locally employed staff there, two in particular I guess. The director of clinical programs there is Dr. [J.] Wysler [Domercant], and he's a very, very capable clinician, epidemiologist, and working with him on some projects and writing was very fulfilling, I would say. And the same thing for the laboratory LE [locally 17:00employed] staff there, Frantz Jean-Louis--he's recently taken a job in Canada--but just working with him to build his capacity and then his resume. That's exactly what I was looking for was those sorts of relationships.

Q: Was Haiti what you were involved in immediately before the Ebola epidemic?

MARSTON: Yeah. We had been missing a country director for a period of time, been struggling to try and find somebody. Finally we had somebody, and he had just moved to Haiti in July of 2014, and I was there in August of 2014 working to hand over some of the things I'd been doing from headquarters and just help him get set up and started. During that trip I got called to say, could you deploy to the emergency operating center? I said yes. At that time it was a thirty-day 18:00deployment, but it ended up being a little longer than that.

Q: A little bit. [laughs] Do you remember who called you?

MARSTON: I think Mark Anderson called me, who was my boss at the time in the Emergency Response [and Recovery] Branch.

Q: What kind of description were you given immediately of what you were going to do?

MARSTON: I was given almost no description, but it was pretty clear that they needed people, and it didn't matter too much to me, so I was just going to go see what it was when I got there. It wasn't even, once I got there, terribly clear what it was. The way I describe it to people is I was told that my job was to coordinate the international teams, and so I said, who are the international teams? And they said, well, that's the first problem. They had very carefully identified some people to lead the responses in each country, but those people 19:00had been there for some period of time, and [all] the people that had gone out initially [to staff the teams] had been there for some period of time, and everybody was obviously enormously busy and hadn't really had time to plan for the next round of people. So that was the first thing to do, was to find people to replace both the leadership and other critical positions. Then as time went on there became a bit of a coordinating and communicating role. I'm not a subject matter expert in Ebola. So we had a combination of trying to get technical input from the experts, but to coordinate the who was going to be there, and how were they going to get there, and how were they going to get the resources that they needed when they were there. Those were maybe more so on my side of things. And exactly what they were going to do, they would decide, or they would get technical experts to help them figure out what to do.

20:00

Q: So how did you find people?

MARSTON: I have a lot of friends at CDC. I don't know. [laughter] No, seriously. The EOC [Emergency Operations Center] has a mechanism for finding people and for matching volunteers with the needs. I think that works pretty well when there's a small-scale epidemic, but obviously this was very quickly much larger than what CDC had done before, so that system continued to function but it didn't meet all the needs. For the leadership positions it really was a question of let's think through by center who might be a possibility, and I honestly tapped into a lot of personal relationships for that.

Q: How do you evaluate that when you look back?

MARSTON: Well, I would say almost everybody that went out there did a very good 21:00job. I was a little surprised not to get positive feedback on everybody, so that was kind of interesting, because of course I'm picking people that I think would do well. That's a learning experience I guess. But I would say especially for the kind of people I was tapping into, the people that would be team leads or response team leads, if they were unsure about going in the first place, they became sure once they were there. Almost everybody at that level was so compelled by the work that they were--maybe they had said initially, I can only go for thirty days because I have these other compelling personal or professional commitments. But almost everybody, when they were out there, was not only willing to stay longer but actually interested in staying longer because they felt like in the relatively short period of time that they'd been 22:00assigned initially, they had just barely gotten going and that they were really interested in staying longer. It was a new experience for a lot of people. Not so much the people I was tapping into personally, but again this whole system for getting logisticians or epidemiologists out there. For some people I think it was a bad surprise, and they weren't necessarily--it wasn't what they expected. It was maybe harder, or scarier, or their personality wasn't really right for it, and we certainly had some people come home. But way more common was the kind of thing where people, once they got out there, were interested in staying much longer. That larger number of people who hadn't done this kind of thing before but kind of found their magical thing that is what they want to do going forward. So that whole, you know, finding people, I didn't feel bad about it. I think it was an opportunity and people saw it that way, and I think if 23:00they were asked to take a lead position they either felt honored, or that they had a responsibility, or both, and mostly it was pretty rewarding. Of course, that's one of the great things about the EOC is when you do a response you get to see people that you haven't seen in a long time, or meet new people across the agency, and, again, not to a one, but to a most, very hard-working, fun people to work with. So if you have to be there X hours a day, you might as well be with people that you like spending time with.

Q: No doubt. Who were some of the early people you remember recruiting?

MARSTON: I don't know why Jono comes to mind. Jono [Jonathan H.] Mermin was one of the people I called. He's a center director. He's a personal friend of mine, but he's also center director [for the National Center for HIV, Viral Hepatitis, STD, and TB Prevention]. I wasn't necessarily thinking about him personally when I called him. I was more so thinking, can we talk through who in your center might be appropriate, but I think he was very interested in participating, and 24:00he was also interested in setting an example for the center to say that, yes, this is really something that we need to support and that by going himself sort of made that clear. That was a fun early recruit.

Kevin. I didn't recruit for his initial deployment, he recruited himself for his initial deployment, but I recruited him for multiple redeployments, including his last one, which was to Guinea, which is kind of interesting. He's a French speaker. In his initial presentation of the idea that he might go to help with the response, the focus was on Liberia, and that's where he went. And then once he'd been there, even though he's a French speaker and we were struggling getting French speakers for Guinea, he'd already been to Liberia and had developed relationships there. So in the trade-off between do I, now that I'm 25:00coordinating all this stuff, send him to Guinea, or do I send him back to Liberia, I chose to send him back to Liberia. So he did multiple repeated visits to Liberia. Then very late in the game we needed him--we needed somebody in Guinea, and at that point we had people in Liberia for longer term, and so the relationships had kind of been taken on by others. It worked very well to tap into his French skills at that time. It turned out that that was for this last cluster in March and April that had actually included spread to Liberia. To bring him around from the other side helped with the communications with the Liberia team, because he had those relationships, and he had the French skills to help make him appropriate to lead the team in Guinea. So I think that worked out pretty well.

I guess the other person I have to mention that I sent was my husband. [laughter] My husband was a division director at the time [note: Larry Slutsker, Division of Parasitic Diseases and Malaria]. I think if anything makes you pause 26:00and say, is it safe to send people to these places under these circumstances, it's would you be willing to send your husband. I guess I thought it was safe enough to send my husband. It was a time, you know, there were legitimate fears, but when people found out that he was going they'd go, aren't you scared? And I said, yes, but to be truthful, I'm more scared about a road accident or something like that. There was Ebola transmission in the community at that time, and we had some scary situations where deployers did have exposures or potential exposures, but I think, just to keep it in perspective, the overseas work that we do as an agency or as a community of people doing international health--I think people take risks all the time, and there are bigger risks than the Ebola risks were. It was helpful to have that perspective and say I'm scared about the 27:00Ebola, yes, but I'm scared about the road safety, and that's not any worse than what he's done in other places. So I think it's a reasonable risk to take. There are risks everywhere. When I was living in Kenya my family worried about me, but my sister in Brooklyn had the World Trade [Center] towers and that big loss of power, and basically more scary things happened to her than happened to me in Kenya. You can't predict.

Q: Yeah. Wow. I want to come back to that issue of evaluating need and risk. Can I ask though, when you were calling these different departments, or these different divisions, excuse me, were there some you focused on? Which divisions supplied a lot of people? Which ones--

MARSTON: Well, the two big suppliers were the National Center for [Emerging and 28:00Zoonotic] Infectious Diseases and the Center for Global Health, and that makes sense based on expertise and relevant experience. It also happens to be the groups that I know the best, [laughs] but that's not a coincidence. The people that had worked overseas previously brought tremendously important skills to the table with respect to setting up contracts with car companies, or making money available to pay for supplies that were needed, or things like that. Both groups I think brought the needed skills for the relationship with the Ministry of Health, and the interaction with the communities, and the language skills, and sort of--I'm going to say--"field hardiness." Lots of people are probably field hardy, but those two centers have a whole cluster of people that are proven to 29:00be field hardy. They were very important sources of deployers. Not to say that others weren't, but those two I think were the big centers.

Q: Were there some unexpected sources?

MARSTON: Well, within the agency--I mean, again, there were some people that just went because they wanted to be part of it and turned out to be fantastic, sort of unknowns that were great. That's a great kind of surprise. One specific group that we tried to tap into was people that had been Peace Corps volunteers, and I forget the numbers, but there are hundreds of former Peace Corps volunteers at the agency. Even if what they do now is related to cigarette smoking, their experience as Peace Corps volunteers really served them very well for participation in the response, both from the standpoint again of that field hardiness or comfort with overseas work, but also language skills. That was a big need for us was French speakers, so it was a good way to find French speakers.

30:00

Q: No doubt. When did your husband go over?

MARSTON: He went in November of 2014, the first time.

Q: November 2014. How long was he there?

MARSTON: For about seven weeks, six or seven weeks I think.

Q: How was your communication during that time?

MARSTON: A piece of cake. [laughter] We go back far enough to have been in situations where our only way of communicating was satellite phone, or every once in a while, if you write an email, there's one time in the day where somebody can upload it and send it. But we could talk or email pretty much every day and probably most times of every day. The communications are lousy in all three of these countries, but we had enough multiple sources of things that there was almost always a way to communicate one way or another.

Q: So how were you getting your sense--from who were you getting your sense of 31:00how things were on the ground in the three countries?

MARSTON: We would have regular calls with the teams, partly to hear updates from them, partly to share advice or updates with them. Then I think maybe most importantly to allow them to share experiences with each other. If one group had figured out how to deal with a certain situation they could share that experience with others, so we'd learn from that. Then I guess as people came back, talking to them about what the experience had been like.

Q: It sounds like you'd be in a position to kind of--you know, you should talk to this person, because they have been through something similar, facilitating discussions like that.

MARSTON: Exactly, yeah. There are a lot of examples, but one compelling example of that was in Liberia. Once disease had come into Liberia it quickly spread to 32:00and then within Monrovia, and the vast majority of the cases were in the area of Monrovia, but there were quite a few situations where somebody either got exposed or sick in Monrovia and then traveled to their rural home and sparked a new outbreak there. The ability to deal with those "sparks," so to speak, or these rural outbreaks, that was something that took some trial and error and really development of ways to approach that. There was a strategy called the Rapid Isolation and Treatment of Ebola, the RITE strategy, that was used in Liberia and then adapted in the other countries. I think that was one example of something that was very useful from country to country.

There was a lot of discussion across countries about what to do at a time when there were not adequate beds and how to deal with providing care when there weren't enough Ebola treatment units. People would show up, and here are strategies that you could use. You can try to add beds. That takes a certain 33:00amount of time. You can try and decrease the amount of time that people stay in a bed, and that was an important strategy. The habit prior to that had been wait until somebody has two negative blood tests before they get released, but a lot of the people that were still in the Ebola treatment unit, having survived Ebola, still in recovery, were in much better clinical circumstances than some of the people that didn't yet have a bed. So you can make a case for earlier discharge of those people and then let some other people come in to the beds, but even with those kinds of strategies there were periods of time where there just were not enough beds, and people were turned away at the treatment units. Then you think, well, could we at least give you some information or materials to help you get decent care at home, or in the community? A lot of discussion around how to provide care in the community. I think the most straightforward thing that could be done is if somebody had survived Ebola, there's a good chance that they could safely provide care to somebody else who had Ebola. But 34:00there were also a series of no-touch strategies that were developed, so if your loved one was sick you could take care of them without necessarily endangering yourself by--putting, you know, liquids on the chair for them [to drink] but not actually touching them, and helping to provide those strategies from country to country. Because we were collectively in some previously uncharted territory.

Q: Right. No, that's fascinating. I had known from speaking with Kim [Kimberly A.] Lindblade before--brilliant.

MARSTON: [She was] behind the RITE strategy that I just talked about, by the way, and also one of the few people that had been to all three countries, and a personal friend of mine, and recruited by me for her first try.

Q: Okay! [laughter]

MARSTON: We worked together in Kenya.

Q: Oh, that's awesome. I think maybe I knew that. Malaria? She--

MARSTON: She was working on malaria then, yeah.

Q: She was working on malaria.

MARSTON: And fabulous at that, too, by the way.

35:00

Q: But she had been talking about the need to take people, as soon as they're sick, from the community, to get them out as soon as possible, because so much transmission happens in that period when they're in the home. I hadn't considered before--what does that mean for the facilities that have the beds, and those beds are already full? Does it mean you'd release people early, or what does it actually--the broader effects of what that actually means is kind of amazing to think about.

MARSTON: Yeah, I mean, in the end what it means is if there's an Ebola outbreak you have to get on top of it as fast as possible. But under these circumstances where it was out of control, there was a period of time where people were turned away from treatment centers but didn't have any place else to go. So what Kim was talking about really became important at a time when there were beds. What you don't want to do is encourage somebody to go to a treatment unit and then have them be turned away. People would lose faith in your advice under those 36:00circumstances. That's behind the whole effort to build enough beds. I think people with their crystal retrospectoscopes can look back and say, wow, the US government built more beds than were needed, but I, along with many people I think, would prefer to have too many than too few. It was impossible to predict with certainty what was going to happen, and what we needed to do was ensure that there would be enough beds. It took a long time to build the beds, and it would have been better if we could have snapped our fingers and had beds instantly. But there was a bit of an over-build, which again I think is better than an under-build, but also had some interesting--just visibility and faith in the world is here to respond with us. That sounds slightly crazy, bringing the US Army to build treatment units just to help people build their faith in the response, but I don't want to undersell that. That's not why it was done, but it 37:00had that effect, and I think that was important. We would have really been in a bad situation if we didn't have adequate beds once we took on the effort to make sure that there were enough beds in Liberia. There wasn't as much of an over-build in Sierra Leone and luckily in Guinea, we basically never exhausted the bed supply in Guinea, but we worried about that for a period of time.

In Guinea, for reasons we don't understand, in Conakry--for months everybody that was found to have Ebola in Conakry, you could figure out who they got Ebola from, and they were all people that you knew where they'd gotten it. There wasn't this uncontrolled transmission in Conakry, at least for a period of time. Things just didn't explode the way they did in Freetown or Monrovia, and I still 38:00don't know why that was. But there was a period in very late 2014 where it was no longer true that everybody in Conakry had an identifiable source. At that point you start to get more nervous that there's transmission and that there's going to be an explosion, and then you look and see how many beds do we have and maybe not enough. We had a few nervous moments there, but never really exhausted the bed supply in Guinea. But both in Liberia and Sierra Leone there were periods where there weren't enough beds to go around, so these other strategies I was talking about before became important. I think what Kim was really talking about is once there were enough beds, the faster you could get people to go to them, the much, much better things were for control.

Q: Right. That makes sense. You know, I had imagined you doing this coordinating 39:00work, recruiting people and making sure they're okay, but you're also involved in considerations of how many beds there are. You had a few roles.

MARSTON: Yeah, it's like a jack of all trades, master of none sort of.

Q: I don't know about master of none.

MARSTON: No, no, no, seriously. It's a very--

Q: I guess that's what a response is.

MARSTON: Yeah.

Q: You can't afford to be a master.

MARSTON: Right. I mean, we had people that were experts in certain things, but that wasn't my role. It was to know enough about enough things to sort of figure out, we need help with this, or we already know what to do with this, or we need more--

Q: Right. How did you come to advise on the strategy for the response, in addition to doing that work with coordinating people?

MARSTON: Well, as I said, so we're getting these teams together to send them out 40:00there. To know who the right person is you have to have a sense of what's needed, so I would need to know it for that. Then I also did my best to get people ready to go out there. Obviously one of the hardest things in here is these thirty-day rotations that we were dealing with early on. It's impossible to pass on thirty days' worth of activity to the next person with a Vulcan mind meld or something. So I would spend a lot of time with people that were going out as team leads to try and explain the background, and what we'd been through before, and try to build the institutional memory of that person, so that when they went there and got the sign-out from the current team lead they would at least have a framework for organizing the information that they received when they got there.

Q: When was it along in the response when you really started to kick that into gear, prepping people on the subject matter before they arrive?

41:00

MARSTON: From day one, although I'm sure my ability to do that prep improved over time. I'd try and pass on what I understood about the history of the epidemic in each country, or the situation with respect to the response, or more mundane things like who was on the team, or what did the contracts look like, or what were the ways that you could move around the country, what were the transport options, things like that.

Q: Did you hear back from people once they had returned about pre-deployment briefings?

MARSTON: Yes. I would say the general feeling was they were all very helpful, and, by the way, they wished they'd had more, but there's only so much that we could do. One of the good things about the time schedule for the response was you never really felt bad that you weren't doing enough, because you couldn't do 42:00any more. You could do different, so you could prioritize differently, but it wasn't--

Q: There are limited hours in a day.

MARSTON: Exactly, yeah.

Q: Well, that makes sense. I also had the chance to interview Rick [Richard W.] Klomp and some of the resilience people, and that's been kind of neat. I don't know if you were coordinating with them at all?

MARSTON: A little bit. That was an interesting interaction, too, because the spectrum of people that went, went from people who thought there was a need for way more resiliency kind of interface to people who felt like there was way too much assistance with resiliency. Trying to get that balance right was a tough thing. I think in general--in general, the team leads were people that were comfortable with situations and didn't have as much shared perspective with the 43:00people that were going out for their first time and wanted more care to those kinds of things. I don't know if we got the balance right or not, but it was always a balance between trying to do everything we can to ensure safety and resiliency with not having that be so consuming that it interrupted the response itself. You don't want somebody who should be meeting with the minister about the latest cases and where they're going to be taken care of spending their time counting the people on the team, yet you want to make sure you know where the people on the team were at all times. We formalized some of that, and I think that was probably the best thing to do was to have these safety officers as part of the team. There are plenty of safety issues. Some people felt like there was a need for way more than that, and some people way less. We just try and keep the concerns balanced and hopefully it lands somewhere in the middle.

44:00

Q: That brings up a really important topic, I think, that's come up a few times in the interviews, which is the very pressing demands of people who are in the field [from] the areas around them, the communities in which they are, and their jobs, and then also to reporting data back to headquarters, and responding to both, both people around you and people in Atlanta. Can you talk about that?

MARSTON: Well, it is an interesting balance. Almost always I would lean toward what the field thinks they need to do is what the field thinks they need to do, and to try and protect that, and to do our best to answer queries--to have the conversations we need to have with the field to get them what they need and to gather the information there that we can then feed up to the National Security Council or the White House or whomever. I think the hardest thing is when one's 45:00personal judgment is the information that's being asked for isn't actually necessary, and then being put in a position of trying to gingerly ask the people in the field, okay, we don't quite see the need for this, but we're really getting a lot of pressure to provide this information--could you quickly provide this? There's ways around that, obviously. If you have somebody who's just come back, you can try and get the answer from them instead of bothering the people who are in the field now. Every once in a while we would just gently push back with an estimate or an answer that wasn't quite what they asked for, but hopefully would meet the need. And every once in a while we'd just bite the bullet and say [to the field], "Sorry. This might not be a priority from your perspective, but we've been really asked to provide the information." I think it's an important job for us to protect the field from queries. At the same time, it's really important to understand that if the people at the White House or wherever aren't getting the information they need, then you may not get the 46:00resources that you need to do the response. That's probably harder to see in the Ebola response than in something that's a little bit slower paced, like the HIV programming. One of the biggest things of PEPFAR and the HIV programming is this reporting back. People are like, it's a waste of time! You say, well, it's not a waste of time, because if you don't do it, you won't get the funding to carry on the programs. It's a little bit like that in Ebola, only faster paced. You hope that the authorities that are responsible for providing the resources trust you when you say this is what we need, and to a great extent they did. If the president asks for information, the National Security Council isn't likely to say, sir, you don't need that. We won't ask for it. So it sort of trickles down. Some of those queries we just had to get answered because we needed the support and resources that we were getting from the government.

47:00

Q: Do you remember some queries that were really important to get answered?

MARSTON: You know, like unreasonable requests. I'll just give an example of that. There was a time late in the response in Liberia--I don't know if you've talked about this in some of the interviews, but one of the things that the US government did was establish a medical treatment facility that would provide care for providers. That was a really an--

Q: MMU [Monrovia Medical Unit]?

MARSTON: --important step to be taken, right, the MMU. During the time of the response there were probably at any given time hundreds of healthcare workers that were in facilities where there were cases, and therefore were potentially exposed, [but] not somebody that had really had a known contact. Very late in the outbreak, at a time when we were able to really focus in on each individual case, there was a situation where a case went to one of the hospitals there [in Liberia]. Then the National Security Council found out there were thirty healthcare providers there, and they go, oh my gosh, that's more than the MMU capacity. We're making all these contingency plans for dealing with thirty 48:00healthcare workers. I was trying to politely explain that we only know that there are thirty because we can pay attention now. If you'd asked us a month ago, there would have been way more than thirty potential people exposed, but we weren't making the same kind of contingency plans. Anyway, does that make sense?

Q: Yeah, that makes sense.

MARSTON: Their thought process made sense but wasn't quite--

Q: Right. Oh, now we have a number, and it's really big.

MARSTON: Exactly.

Q: It sounds really big, and so we have to get on--

MARSTON: We spent a lot of time developing contingency plans and feeding up information about what it would take to expand this treatment. It wasn't any more necessary than it had been a month ago. I won't say it was unnecessary, but it was sort of out of place. But we absolutely had to do that anyway. That's an example.

Q: What's something you had to push back, that you actually could push back on, and it was okay?

49:00

MARSTON: Oh, just things like the numbers of contacts. Here's a good example. Contact tracing is really important in Ebola. You have to find everybody who's been exposed and track them, and the most important thing is that you find everybody that's been exposed and you track them. The second most important thing is that you know how many people of those that there are. In other words, the person in Margibi [County] has to know how many people there are in their county, and the person in Sinoe [County] has to know. But if Monrovia doesn't know the total, as long as the people in the places know, it's okay. But there was I guess a lot of feeling that if I couldn't answer the question of how many contacts were there, that we probably weren't doing a good job. But that's not necessarily true. So you could push back on that a little bit. They'd say, how many contacts are there, and how many have been followed? And we'd say, we don't know, but it's okay because what we're hearing from each place is that there was full contact tracing, things like that. So then you would be able to give--instead of saying 4,627, then you would say, well, we don't know exactly. 50:00We'll get you the counts later. But our understanding is there's full contact tracing in each place. Or something like that.

Q: Right. That makes sense. It's like, yeah, perhaps we don't know, but we know that they are on top of it.

MARSTON: Exactly, right.

Q: And they're the people who need to be on top of it.

MARSTON: Right. And the energy--it's usually something like that where me not knowing makes it look like it was not a good job. But that's--

Q: But that's totally not the case.

MARSTON: --actually not the case. And it's not worth their time to put that information together to send it up. It would be more important that they actually go and trace those contacts. So that sort of situation.

Q: Good example. [laughs] I'm going to take a--what moments in 2014 do you look back on as being important for, I don't know, being milestones in your part of the response, or shifting the response in one way or the other?

51:00

MARSTON: From my part in it, I don't know, just my thinking. I have never personally been so frightened by an epidemic, ever. I remember when I wasn't deeply involved in it, the Global Disease Detection group puts out a newsletter every day about the numbers of cases, and you just watched that case number just go up, and up, and up, and up, and you think, it's higher again, it's higher again. I was starting to appreciate what was happening and the rate of spread, and it was at a time when the rate of increase really was enormous. And if that were to continue in line with the models that were produced at that time, there were incredibly scary scenarios where you start thinking we're going to have to do things like military drops of supplies, and stop sending people in, and wall places. You know, really radical ways of dealing with an epidemic that we just 52:00hadn't dealt with before.

I think it's easy now because it's been controlled, but at the time I wasn't 100% sure that it would be controlled. I know a lot of my friends are very cognizant of that. They look back and they go, you were really scared, weren't you? And I was like, yes. I was really scared. I don't know when I started really getting the impression that we could control things. It was basically when the curve started tipping downward. The minute you turned the curve, then you start feeling some faith that you can control it. There are two kinds of phases like that. One is turning the curve and getting some control, so getting away from just exponential growth. But then there's also--and it was more so in Guinea and Sierra Leone than in Liberia, but there's this feeling at the end where you're like, almost, and then there's one more case, one missed contact, or one person that--in Guinea, that went on for months. In Sierra Leone it went on for a good period of time, too, where the numbers went way, way, way down, 53:00but we couldn't seem to just finally get a hold of it.

So I guess for me and the response, those were kind of two big things. You don't know exactly when--you don't know when it's controlled, right. The day it's controlled you don't know if there's going to be another case tomorrow or the next day. You have to wait a while and then look back and say, oh, that's when it was controlled, or that's when things turned around. I think most of the response bits, we celebrated various marks like the hundredth day of the response, or the thousandth deployer, or whatever, but it's all oozy. There are hardly any ta-da, this was this day, or this was that day. It's really much more kind of a little bit at a time than that. So I don't know.

Q: I hear that. In my mind I imagine that's partially a function of just working 54:00so many hours.

MARSTON: It is. But I mean just stuff doesn't happen in neat packages like that.

Q: That's also true.

MARSTON: You kind of semi-get-a-grip on the numbers of people that you need to send out for staffing. An example would be we need country teams. In the middle of this whole thing, we've stood up country offices. Having a real country office, that is something. But how do you know when you have a real country office? When you have a director, or you have a director and a deputy? Or a director and a deputy and an epidemiologist? It happens stepwise. Like right now I can tell you we have an office in Liberia, and we have an office in Sierra Leone. I don't think we really do yet in Guinea. We have a director and a deputy, and we've had those for a while, but I can tell you that's not enough to count. It's really whenever it tips from you're still sending most of the support on a regular turnover basis versus you can really count on the country 55:00office for most things. But exactly when that tips, I don't know.

Same thing when we meet our needs for staffing. There was never a time in the response where we could sit back and say, ah, I got that done. It was always a struggle to find enough. Even now we struggle a little, but finally now we're in a situation where we have a staffing plan that goes out for a few months, and we sort of know who's going. There are only two or three critical spots to backfill, and those are mostly because somebody got sick or something unexpected happened. But when we turn to that, I don't really know.

Q: Yeah. No, you're right. It's kind of an artificial thing when we look back on the past, and we didn't decide that--there were single moments when in fact things are more complicated and evolving.

MARSTON: Or like we deactivated the response on March 31st, in the middle of an ongoing cluster. [laughter] I don't know what was magic about that day except 56:00that that was the day we chose, and that's the day we turned it off, but there was actually ongoing transmission at that time and a couple of cases that were identified after that. I don't know.

Q: No, that's good. That's good to remember. Do you remember what little celebration you did for the hundredth day or the thousandth deployer?

MARSTON: I think the hundredth day President Obama called us. Yeah, so I do remember that. I remember we didn't get a ton of warning, so my job in that case--President Obama didn't want to talk to me, he wanted to talk to the folks in the field. So I was just desperately trying to get in touch. As I say, you could always get in touch, but not necessarily right at that moment, so I'm really trying to get in touch with the people in the field to let them know that President Obama would be calling them. I was going to feel bad if I missed any country, but I think we got them all, so they were ready to receive that call. 57:00That was pretty cool.

Then, let's see, the days I remember, 105 I think was Halloween, and I only remember that because the incident management updates always say day whatever of the response. Inger [K.] Damon was the incident manager at that time, and she has a little bit of a thing for Despicable Me and the minions. So my daughter and I printed off some copies of Minion faces and stuck them on popsicle sticks so that when we announced it's Day 105 of the response, everybody went like this and put up a minion face. All of a sudden Inger was looking at her minions. [laughter] It was kind of cute. But we celebrated Day, I don't know, 300, 500. I think Secretary [Sylvia M.] Burwell may have called on Day 300. But at some point we stopped counting, and so much so that by the time we closed the response we were sick of celebrating the response and decided instead that it 58:00would be most appropriate to celebrate the people who work in the EOC fulltime. We did a little "thank you for your efforts on this and other responses" as opposed to another celebration about the response itself.

Q: Right. Who were some of those people who stand out for you? I know there's probably several.

MARSTON: Oh, gosh. Well, there are all these--the EOC has people that work there all the time, right, like Ed [Edward N.] Rouse, and Mark [Carl] Fletcher, and Kevin Gallagher. I've probably missed a million people. But we made certificates for them, and it just brought them up. We did a video. Now when I say "we," Schabbethai [Sainvil], who works with my group, did a video--and Abdoulie [Senesie]--they made a video of people saying thank you. It was pretty cool. Because people count on those guys for the travel and the logistics, the sort of 59:00the mechanics of the response, and it's remarkable what they do. A lot of people, I mean, even me, okay, a year and a half, but it's still a time-limited period. Those guys are there all the time, and if every day is an emergency--the guys that make the slides, they do that for every response all the time. By the time we turned off the Ebola response, there were three other active responses going on, so nobody caught a break.

Q: Yeah, that's wise.

MARSTON: There's some note upstairs that says that the EOC's been activated 91% of the time in the last X years, I don't know how many years, but it's basically the new normal is to have something going on.

Q: Right. How do you feel about that, as an agency? I mean, there were emergencies back twenty years ago, but there was nothing like this.

60:00

MARSTON: That's a hard question. I think what we have to ask ourselves is, does the activation of the emergency operating center substantially change the value of the response? Polio [poliomyelitis] is a good example of that. The EOC is activated for polio, but to me that's largely symbolic. It's really to demonstrate that our agency is super serious about the commitment to polio, and I think a polio response could be run without the EOC being activated, and it would be equally effective, but it wouldn't have the equal symbolic value. I think for this Ebola response there's no question but that turning on the EOC was essential. And it has some interesting impacts. I do think there is this sort of growing new normal where, for example, the White House and the NSC [National Security Council] pay close attention to things that they might not 61:00have paid quite as close attention to in the past, and we have to be careful about that balance because as we were talking about earlier, that can subtract. It obviously adds, if that means bringing resources, but it can subtract just in terms of they may not have the best public health focus. They have a different perspective on what's important and what's not important, and their perspective is valuable, but it might--so when I'm judging it from a public health lens it might not be the same.

For example, if you look at the energy that went into the domestic response to Ebola compared to the international response, we screened a lot of passengers not to find anybody in that screening process that had Ebola. You really just wonder, wow, is that a valuable thing to do? Of course it was from the standpoint of making Americans feel safer and as a just-in-case measure, but I'm 62:00going to stick with my opinion, which is that the most important way to protect Americans from an outbreak like this is to support the response itself and control the epidemic where it is. That's not to say that other work's not valuable, but I think the different lenses might overemphasize that sort of thing compared to the response in West Africa. So having their interest is something we really long for, but not if it keeps you from doing what you need to do. I'm not saying that it did, but I think there's a danger of that if the focus gets too distracted to politics or appearances, that can be problematic. So we have to just watch it. But I'll tell you what, President Obama came here on September 16th, 2014, not that I remember that. [laughter] But I think that 63:00was a pretty impressive--I mean, he demonstrated his ability to receive information, absorb it, interpret it, turn it around into support for the response, and that was incredibly important. At one level you'd say, well, how important of a use of time is that, to have a visit and to do these things? It was incredibly important because it was shortly after that that we got the military support and funding and attention that was needed to turn this. Anyway, we'll just keep the balance as close to correct as we can.

Q: Yeah, that makes sense. This is probably something that's delicate, and I don't know, perhaps you might want to use--not pseudonyms but just general language about it, but I'm wondering about evacuations. Because that's something 64:00that we haven't actually really talked about too much here, is CDC exposures. Is that something we can talk about?

MARSTON: Sure. I mean, any work involves risks. I think international health work, you take on a set of additional risks. People--in particular there was one CDC staff person in the hotel in Bamako when there was [an attack]. People have been in different situations. I think in general we try to--we're so risk-averse that we seem to want to have a zero-risk situation, but I think for this response, you could think of it as a war and think that honestly it would have been reasonable to expect that there would be casualties of this war. And there were, of course. There weren't among CDC staff, but I think that's a combination of care and luck, not entirely care. Our staff clearly put themselves at some 65:00level of risk, if it's the road accidents we were talking about before, or if it's the possibility of community exposure to Ebola, or the possibility of exposure to Ebola in the context of work. We did what we could at any given time to minimize that, but it's hard to get it to zero. I think one of the worst situations that happened was that one of the responders--not a CDC staff person, but--was coming to district meetings while ill. That's a very awkward situation to be in. It was a medical person who was probably denying to themselves that they had symptoms of Ebola because that's what a normal human would do. You'd say, oh, I'm sure it's just a cold. I'm sure it's--but the right thing to do would be to extract yourself from that situation. That person didn't, and as a 66:00result we had some people that were exposed. [Those that were potentially exposed] didn't get sick, and that's lucky. That was one of the things I talked about when I was calling my friends. I would have this time period where I talked about it and said, well, this is what you do, and this is what I'm talking about time-wise, and what I'm talking about commitment-wise. Then I'd pause and say, well, let's just talk about this for a second. Before you go, I want you to really understand that we're doing what we can about these things, but there is community transmission of Ebola and you have to know that going into this you'd be potentially taking on that risk. We all make these kinds of decisions in our lives, and for the most part people took an assessment of that and thought, that's a risk that I would be willing to take. I think it was frustrating how difficult it was to try and deal with some of the risks, and the 67:00whole situation makes you frustrated with the world and the world inequities. What I mean by that is we think of Ebola as this terribly killer disease with mortality rates of 50 to 90%, but the mortality rate among people who were evacuated and treated in the United States and Europe was way lower. It was more like 20%. So it's not that medical care could take care of everybody, but really good medical care improves your chances dramatically. This is a frustrating thing for everybody. If you go into a famine situation, as a famine worker, do you eat? You have to eat, because if you--I mean, who would go, and then go and not eat? Like the refugees, you wouldn't be able to do the work, yet you're in that very awkward position where somebody in front of you doesn't have enough food, and you do. Well, it's the same thing here. I think there are people who 68:00are willing to go without the guarantee of medical care, but I think as a human being with a family and an agency and whatever, we all want to minimize that risk to the extent possible. Anyway. So we want to minimize it. We want to say, we're going to send you, but we're going to do everything we can to keep you safe. We're not going to guarantee that you're safe because we can't. But we're going to do what we can. So set up the MMU, have medical evacuation. But the United States has rules against allowing people into the country if they have certain infectious diseases, if they're non-American citizens. We at CDC have people on staff who aren't American citizens who are willing to go and do this work, in many cases would be the people that were the best prepared for it from a language skills or an experience standpoint, yet we couldn't send those people because I didn't feel like the balance was right. It's not just me, we as an agency didn't feel like the balance was right, that we could tell them we're 69:00going to send you but if there were a problem, we can't assure you that we'll bring you back to the United States. Eventually, for some deployers, we made assurances that they would be able to go to Europe in accordance with some of the evacuation procedures that WHO [World Health Organization] had set up for people from all countries, because it doesn't make any sense to evacuate somebody from [the setting of the outbreak in] Liberia to Angola, or to a country that doesn't have the capacity to contain Ebola. It doesn't make any sense. So they made arrangements with treatment facilities in Europe to evacuate people there. I can't remember what question exactly got me going on that, but that's one of the hardest things is to figure out that safety risk and are we doing enough. You can't prepare for every situation. I think the part that ended up making me the most uncomfortable would be moving people within a country. We 70:00finally did get a pretty good system for a medical evacuation by plane once somebody was in a place where a plane could reach them, but there are a lot of unknowns depending on where somebody is at the time about how you would get them as safely as possible to a place where they could be medically evacuated. You'll have to remind me of the question, but that's--

Q: They're more prompts, they're not like direct questions, [laughs] but thank you. I don't know if you can describe in more detail one of the places or situations where it seemed like the balance was not in the favor of sending someone there, that maybe there was too much risk?

MARSTON: Only after the fact. In other words, we didn't figure it out ahead of time. But I think there were situations where people were either exposed or 71:00potentially exposed away from the capital city and that we ran into this problem of how would you move somebody safely. I feel like, not that we shouldn't have sent them, but that we should have probably done more in advance to figure out how we would move somebody around the country. I think the only times we slowed sending people were related to political unrest. And then there were situations that we wouldn't put our people in, so with rare exceptions we didn't have CDC staff going into medical facilities where Ebola patients were cared for. That was uncomfortable for some people and very reassuring for some people. I think it probably goes to your situation and your level of training. The very experienced people would be like, I should be allowed there, I know how to do 72:00it. And again, there were a few exceptions where we did, based on somebody's experience, allow them to go. I think people were a little bit frustrated by that, but also probably slightly relieved by that, not to be right in the zone. It gives me tremendous respect for the people that went, as clinicians, and did that. It was a little interesting, going to an ETU [Ebola treatment unit] in Liberia in February of 2015. Things were pretty quiet by then, and there were a few clinicians that were working in that ETU, but they hadn't had an Ebola patient during the time that those clinicians had been there, and they were really frustrated because they had sort of geared up for that and were ready for it. Once you're ready, you're kind of I'm sure partly relieved that it doesn't happen, but also in some ways weirdly disappointed that you didn't end up being able to capitalize on that training that you'd taken and participate in that 73:00way, if you'd made the decision that you were willing to do it.

Q: Yeah. Now, again, I don't know to what degree the military metaphors are completely acceptable. John [T.] Redd has talked about that actually. But you hear about that in the military, too. It's not somebody who joins the military and wants to go over and kill someone, or be in combat, but when you do all of this preparation and nothing happens--

MARSTON: Yeah, there's a letdown of some sort.

Q: Yeah. Let's talk about the Haitian responders, if we can.

MARSTON: Okay.

Q: You were in Haiti setting up the FETP [Field Epidemiology Training Program] program, as you said, like one of the things you're really proud of that are sustainable in Haiti potentially. How did they become involved in this response? I guess it wasn't an easy process at first.

74:00

MARSTON: Well, it's a complicated story, but obviously for the response in Guinea we needed French speakers, and as much as we--at one level I'm dumbfounded by how many people at CDC speak French. There are hundreds. On the other hand, we tapped through--we went through that group pretty quickly, and we needed to think creatively about how to get other French speakers. We had a couple of different ways to get French speakers that worked out very well. One, I think the most amazing one was responders from the Ministry of Health from the Democratic Republic of the Congo. There's been a longstanding FETP program there, and we called the resident adviser and asked whether there was any chance that there would be people who would deploy, and he thought yes. He's, "Well, how many?" He said, "Five?" I said, "I don't know. How about--" Well, actually I think I took five initially, and then I called him back later and said, "How about ten?" Basically for months on end and continuing to this day, the DRC has 75:00been sending five to ten well-trained epidemiologists, most of whom have graduated through the FETP. They're fantastic deployers because they bring field readiness and language skills and cultural appropriateness, which is, you know, you can't undersell the importance of that. If you send me into a remote village, people are like, who's that? What is she doing here? Whereas if you send somebody from the DRC who speaks French, he can explain, and it goes better. So they've been tremendous.

There are a couple of really phenomenal groups. The Public Health Agency of Canada is a group that we tapped into, and we could tap into both their English and French speakers, because they have these epidemiologic skills. But we specifically tapped into them to try and get French speakers, and we've ended up with scores of people from that agency deploying. We had a couple of other good mechanisms. But once we'd done this with the group from DRC, I did try other 76:00countries and didn't have too much luck for various reasons. We tried a couple of different ones.

Q: Like which ones?

MARSTON: Well, we tried Morocco. We really struggled. I think the big thing in Morocco was that Morocco didn't feel comfortable with the idea that people would be coming and be part of the CDC team. They wanted to send a Moroccan team. In the end I don't think they ended up doing that, and I can totally see that perspective. What we did with the DRC was the group from DRC became full-fledged members of the CDC team. We supported the logistics and things like that. DRC is getting lots of thanks and kudos, but it's not seen as a DRC team. They're sort of seen as part of the CDC team, and I can see from some countries that would be frustrating.

Other countries were concerned about people deploying and then returning, and Haiti early on, fairly enough, was worried about that. Obviously if somebody had gone to an Ebola-affected country and come back with Ebola to Haiti, that would 77:00be an unmitigated disaster, or maybe it would be mitigated because of the experience they've had with various things. But it's not a risk that they were interested in taking. They were really wanting to be very cautious about avoiding travelers from West Africa during the peak of the epidemic. But as things came under better control and we were able to be more reassuring that we'd had hundreds and hundreds of deployers without anybody getting sick from the CDC team, they started to consider sending people from the CDC office. The same people that I mentioned before that were good colleagues in Haiti ended up being part of the response, along with several others, and really brought fantastically helpful inputs. Because on top of all the field hardiness and language skills, they have the specific experience that is so relevant with some of the recovery activity, so establishing transport systems for lab specimens or setting up general surveillance systems are things they've just been through. 78:00Not only do they have ideas about how to do it, but they will say, "here's the form that we use," and it doesn't have to be adapted that much. You can cross out "Haiti" and write "Guinea." Maybe adapt more, but it's a lot better than taking something from English, whatever. Eventually we tapped into some FETP-trained Ministry of Health staff from Haiti in the same way that we have done that from DRC. I don't want to take too much credit for the FETP, but that was part of the program that I was involved with. I wasn't specifically responsible for the FETP. It's very special in a couple of ways. Haiti has a reputation of being one of the most difficult places from a public health standpoint in the western hemisphere. I think that feeds into this thinking of Haiti as the worst. Haiti's the worst. People say it's the worst in the western hemisphere. It still has a ton as a country to offer to many other countries and 79:00to be able to see these skills put to use--these two particular deployers, the FETP-trained staff from Haiti, were just so well received in Guinea and were so able to support some of the programs that were being established there. I think it's just very gratifying and maybe good for Haiti's ego, if you will, to say, hey, look what we're able to do. Dr. [Thomas R.] Frieden has a pretty close relationship with some people in Haiti, too. The Minister of Health has turned over since our deepest involvement there, but just to be able to go there and say, thank you for your contributions, and this is what Haiti's able to do to support the response. I think it's great, the whole Africa supporting Africa, Haiti supporting Africa. It's very well that the United States or other well-resourced countries make this support, but I think it's cool when other 80:00countries bring something to it, too. And as I say, they bring something that we couldn't necessarily bring ourselves, and very well appreciated.

Q: When you mentioned those two Haitian FETP grads, were those the same that you had mentioned before, the same people?

MARSTON: No, I think the ones I was talking about in detail were locally employed staff in Haiti.

Q: Oh, those are locally employed staff.

MARSTON: Those two went as well, Wysler and Frantz went. Frantz went--I think they've both gone multiple times and also just enormous [contributors.] But these two from the Ministry of Health, they're basically the first two that went through the advanced training program for FETP in Haiti. They were just fantastically received in Guinea, like people couldn't stop talking about how useful their contributions were, and that was pretty gratifying.

Q: Do you remember their names off the top of your head?

MARSTON: Sure. Samson Marseille--I don't know if I say his name right--and, I 81:00mean, let's say Samson Marseille and Salomon Corville. I just think of them as Samson and Corville, but, yeah.

Q: Gotcha. Well, thanks for that. [pauses] This is an impossibly broad question.

MARSTON: Okay. Try me.

Q: Yeah. We've covered a lot. Are there any other memories, when you look back, that stand out to you that you'd like to share?

MARSTON: I didn't go to West Africa until February of 2015. So here I was doing all this--you said, "How do you know what it's like?" I only knew what it was like in talking to people and calling people and seeing photographs and whatever. There's a big part of me that really wanted to be there. In fact, I gave a presentation at Georgia State University. I was trying to help people here understand what we were doing and everything. Almost like Alcoholics Anonymous, I kind of had to say, by the way, I haven't been there yet. I'm going 82:00to tell you the story of it. I did get to go in February and just at least touch things a little bit. Most of that was office-based work, trying to get things set up, but very happily for me, when I was in Sierra Leone, John Redd took me out doing some contact tracing. I was--I don't know why I'm talking about this, mostly to say that it's--just to express how fulfilling that work is, even that one-day field trip. Then I went over to Liberia, and I went out to the field there, too, and there was a young woman who was supporting the activities in Margibi County. She was a CDC staff person. But I was able to talk with her and give her some suggestions for things. She says, "Oh, I hadn't thought of that," and "Could you stay?" I was like, "Oh, I'd love to stay." Then I called back here and they're going, "No. You have to come home." I was like, ugh. It's just mostly to say I think we feel gratitude to everybody that went, and I don't want 83:00to diminish that at all, but it is--it's a very lucky thing to be able to do, too, and just to encourage anybody that's interested in doing this kind of work. It's fun. It feels good. If you're going to spend your days doing something, why not be out walking around Waterloo in Western Area Rural [District], checking on somebody who's--it's interesting and it's compelling work. I think that's one of the coolest things is these couple--like John Redd's an example. I don't know if he told you this or not, but my understanding from talking to John is he has found his passion. He's been working in public health for a long period of time, but this international work, working with the Ministry of Health staff, this is him. This is what he does. He's done it great, and that's what he wants. So he's 84:00changed careers basically from what he did before, and then he went on a temporary deployment. He's like, this is what I want to do, so he's now part of the group that's doing this full time. That's kind of cool.

This one thing that I remember specifically is the end of the main epidemic in Guinea was a kind of a--it was very frustrating in some ways, because the very last few cases were all children or pregnant women. There's a vaccine for Ebola, and it was being used extensively in Guinea. It wasn't being given to pregnant women or small children because of safety concerns, and that probably had something to do with the fact that the last cases that we saw were in people that had been exposed but not vaccinated. So watching these children--but then there's always this little bit of a silver lining. So the last case in the main epidemic was an infant born to a woman that had Ebola. She delivered and then 85:00she unfortunately died, but the baby survived. That's a highly unusual circumstance, to have an infant born to a woman with Ebola survive. She got a couple of fancy treatments, but just, that. It was also fun because Carmen [S.] Villar, who's the chief of staff, was helping me with some logistics about getting some specific medicines for the baby, and I was able to, "Carmen, the baby's still alive." "The baby's doing okay." "The baby's going to be discharged." You get these little bright sparks of something that--it was nice to be able to be a part of the effort that maybe led to this baby surviving. A lot of people are still paying attention to her, and she should be--let's see, she was born in late October, so she'll be nine months old now or something. But she's apparently doing pretty well. It will be interesting to grow up being that 86:00baby. I don't know.

Q: What does it mean to be the lead of the Ebola Affected Countries Office?

MARSTON: I think maybe nobody else wanted to be it, [laughter] something like that. It's kind of like that Haiti situation in that, once again, okay, it's three countries this time, but instead of doing a little bit of one thing in multiple countries, it's kind of being part of all things in these three countries. It's kind of triple the volume of the Haiti work somehow, because it's three country offices, and staffing for three country offices, and partner relationships in three countries, everything. But it's got a little bit of that again to it, where I get to have kind of close relationships with a number of 87:00people. So I like that. This will be interesting because I think much like Haiti, it's going to be a sort of intense focus for a period of time and then fade. Not to unimportance, but back down to what is happening in other countries and probably instead of having an office focused on these three, it will just get absorbed into the general global health security program, at which point I don't know what I'm going to do exactly. But right now what it means is sort of just having a big part in what is now enormously important. They're high profile, lots of focus from Congress and Dr. Frieden and others. It's always fun to work in an environment like that. It's also still a little bit tiring, and it's a little frustrating because I think the resources are going to go no place but down, and the expectations are probably going to [stay] very, very high. I think the world has unrealistic expectations of how quickly we can build the 88:00kinds of systems that we wish were in place in these countries. So I'm pretty much set up to disappoint. We can report a lot of progress, but we're not going to be able to make these into countries that have robust systems for detection and response without some long-term work. It's a little bit of a funny situation in that way. People have very high expectations. I think my expectation is that if there's any more Ebola, we'll be able to respond quickly to it, and we still hold tight to that capacity. I think we can still--we, the big we--can do that. But what we have to do now in addition to that is try and set up surveillance and response capacity such that if this kind of thing had happened at a different--you know, if we'd had this opportunity to set these systems up ahead of time, that Ebola wouldn't have happened. That's a tall order. Like I say, I 89:00think it's very fun, it's very gratifying, it's bound to be disappointing to some.

Q: Yeah. Of course, your most important partner in each of the countries is the country itself or the government itself.

MARSTON: Right.

Q: But are there international NGOs [nongovernmental organizations] who are there, like IRC [International Rescue Committee], who are kind of long term who are going to continue to be important partners with CDC moving forward?

MARSTON: Sure, and it's different in different countries. It's different in these three countries than in some other countries. Liberia has a long history of US government presence, and there are quite a number of NGOs that have been funded by the US government, mostly through USAID [United States Agency for International Development] over time. But in Guinea I would say the whole idea that to support Guinea we would give money to some other organization was sort of a surprising thing to them. Not that there are no NGOs there, but it's not 90:00their normal mode of operation. It's an interesting one, and it's an expensive way to work, and don't we wish we could just give the money to the ministries of health and they could just execute it. But the reality is that it wouldn't be possible to move as quickly if that's the way we operated, and people want fast. But anyway, I think there will be a growing presence. The US government's not the only source of funding that's come into these countries. There's World Bank money and other donors paying attention, too.

I think it's going to be a mixed blessing. Makes for a very complicated situation to have lots of partners, but we have some solid partners, and hopefully this experience will build them over time, too. One of the observations from early in this response was there weren't partners that had this experience. How could they? Really the only one that had experience with 91:00Ebola control was MSF [Medecins Sans Frontieres]. Throughout this response, other partners have developed the capacity to support Ebola treatment units. Certain partners have developed the capacity to oversee the epidemiologic response, the contact tracing, the safe burial teams. You can always hope that that's not going to be needed anyplace else, but it's also nice to know that there are partners that have that capacity now. We wouldn't necessarily be in the same partner-creation mode that we had to be for a little while in this response. But anyway, the short answer, yes. There will be NGOs that are important partners. But we obviously very much focus on the governments and the ministries as our really key partners.

Q: Okay. Well, thank you so much for being here. I don't know if there's anything else you'd like to add for the record, or any reflections? No?

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MARSTON: I don't think so.

Q: Think we're good? We got a lot. Thank you so much, Barb.

MARSTON: Thank you.

Q: This has been a total pleasure.

MARSTON: Good. Thank you.

END