Dr. Benjamin Dahl

Dr. Benjamin A. Dahl

Q: This is Sam Robson here with Dr. Ben Dahl. It is Wednesday, June 29th, 2016, and we are in the CDC [Centers for Disease Control and Prevention] audio recording booth in the Roybal campus in Atlanta, Georgia. I'm interviewing Dr. Ben Dahl today as part of our CDC Ebola [Response] Oral History Project. So Dr. Dahl, thank you so much for being here.

DAHL: Thank you, Sam.

Q: Of course. And just for the record, would you mind stating your full name and your current position with CDC?

DAHL: My full name is Benjamin Arthur Dahl, and I'm an epidemiologist in CDC. I currently work in the Global Immunization Division as a team lead for vaccine-preventable disease surveillance.

Q: Thank you very much. Can you tell me when and where you were born?

DAHL: I was born in Chicago, Illinois, in December 1971, and that's it.

Q: And that's it. And then you moved--

DAHL: Yes. I was born in Chicago, lived there up until first grade, and then 00:01:00moved to Gloucester, Massachusetts, a little fishing town northeast of Boston.

Q: Is that where you grew up?

DAHL: Yeah. I grew up primarily there, in Gloucester. Didn't really move until I went to college, undergraduate in Minnesota, in St. Paul, at Macalester College in St. Paul-Minneapolis.

Q: What was Gloucester like back then?

DAHL: It was different than Chicago. That was for sure. Chicago, obviously a large city, and Gloucester was a town of about twenty-five or thirty thousand. It was a nice place to grow up. It was right on the coast. It's America's oldest seaport, they say, or fishing town. It was a great place to grow up, being on the ocean. I worked on a fishing boat for several years, in high school and in college. Gloucester's also known--it was a place where they lost a number of fishermen during The Perfect Storm, the book and movie. I knew one or two of the guys that went down. So that kind of tied it back. But a great place to grow up, 00:02:00and my mom's still there, so I get up occasionally.

Q: Yeah. Were you raised by your parents?

DAHL: Yeah. My parents were divorced, but I was raised by both of them. My dad was still in Chicago, so occasionally I would go back there, but, yeah, raised by my mother.

Q: Gotcha. What does she do?

DAHL: She's a social worker, a family therapist, so dealing with mental health issues. Family therapy was her specialty, but then some other things. Family therapy, but then also, Gloucester has a large heroin problem. So there was some drug addiction stuff, but also, HIV [human immunodeficiency virus], because of the sharing of the needles. So that was something that, early on, she was also working on. But something she said, it really changed as therapies changed. Initially, it was mostly just preparing people to die, whereas now, it's more 00:03:00telling people how to survive and maintain some of their--I guess their perspective on how to continue with life, now that it's more of a chronic disease.

Q: And what does your dad do?

DAHL: He was a schoolteacher, a public schoolteacher. He was also a photographer. His training was in photography, so he was like a fine arts photographer. But he also taught in Chicago Public Schools for, I don't know, twenty, thirty years, so that's what he did.

Q: Gotcha. So you were growing up--in high school, you said you worked on a fishing boat. What other kinds of things were you interested in?

DAHL: I always liked fishing. Obviously, I worked in the industry, so that was professional, but I always enjoyed actually fishing as a hobby, as a leisure. Travel was something that was always kind of interesting to me. Started out, obviously, domestically, and seeing a lot of the different states, and state parks and national parks. Then I guess also cooking was something I also liked, 00:04:00and it was something that partly--I guess my mom worked some evenings, so partially out of survival, like not wanting just to eat frozen food. So learning how to cook, but then I grew to enjoy it, too.

Q: What kinds of things would you cook?

DAHL: I think the first thing I probably cooked was, like, Kraft macaroni and cheese. That was big--boiling water and mixing stuff. But it grew into other things, and being in a fishing town, I had a lot of access to seafood, so lots of things like that, and a big Italian community, so a lot of Italian type of food, as well.

Q: So what were you thinking about your future back then?

DAHL: Yeah, it was hard to know. I knew I was going to go to college. Gloucester is a--not everyone goes to college. It's a pretty working-class town. But for me, that was--obviously, I was going to go to college. I had a couple friends 00:05:00who had gone to Macalester before me, from my high school, so I heard about it, and it seemed interesting. It's a liberal arts school with an international focus, so that appealed to me. So I thought I'd go to college. After that, I wasn't exactly sure. But then, as I went through college, knew that I had an international interest, and so I did a study abroad in Chile. I lived there for six months and that was really fascinating. It was a time right after [Augusto] Pinochet had left power, and so it was a transitional period. That was really kind of fascinating to be there after so many years of a dictatorship.

But then after college, I wasn't exactly sure, and I decided to join the Peace Corps. I joined the Peace Corps program and was a volunteer in the Central African Republic. And we were evacuated, there was a coup. That was a little 00:06:00hairy, definitely. My first introduction to Africa was Central African Republic, and I didn't even know it was a country before, or where it was, before really going there. But it also kind of showed me some of the basic needs. I mean, really, living at the village level, you can just see, one, how fortunate I was growing up in the US, and having all the resources we do, but then also, on the other side, what the needs were. But I wasn't exactly sure, even after Peace Corps, what to do, and so I came back. I worked in Washington, DC for Georgetown University for a few years on an international development program. I was thinking that I was probably going to go into that aspect, so more like the USAID [United States Agency for International Development] or State Department. I knew I definitely--global view was what I wanted, global work, and so I was thinking of that.

I guess one thing in--while I was in Peace Corps, one of my side projects was 00:07:00building a community health center. So I started thinking, okay, what do I need to do next? I have my undergraduate degree. I need to go to graduate school. After some reflection, I decided probably health would be a better way to do it. So I applied to a number of public health schools and decided to go to Emory [University], to Rollins School of Public Health, where I focused on infectious disease and global health for my degree. My advisor, I think as I mentioned, was Phil [Philip S.] Brachman, a former CDCer. He, through some of his connections, connected me to some people working in the Parasitic Disease Division of CDC. And so I started as a work-study student at CDC in either 1999 or 2000 and did a 00:08:00summer project with them in Haiti, working on lymphatic filariasis in Haiti. I've basically just been with CDC since then. So I started out as a work-study student, converted to a guest researcher, continued to work in the Parasitic Disease Division.

During that period, I also did my doctorate in epidemiology focusing on African trypanosomiasis and surveillance for that in a number of countries, so in Uganda, Tanzania, Democratic Republic of Congo, Angola, and Sudan. I had a project working with Anne Moore from the Parasitic Disease Division. She's retired now, but she was my advisor or my boss at that point. So we worked together. Also, collaboration with WHO [World Health Organization], because CDC 00:09:00was a WHO collaborating center at that point for African trypanosomiasis. I did that for several years. Then in--I guess in 2009, I joined the Global Immunization Division, working on a different project, working on trying to improve surveillance in Central Africa, in region, so in DR Congo [Democratic Republic of the Congo], Cameroon, and Central African Republic. It was a project that CDC was involved in, WHO was involved in, and it was funded by the [Bill & Melinda] Gates Foundation. So that's kind of what I was working on for a while.

Q: Can you explain a little bit--I loved hearing, when we talked a little bit before, about how you were studying African trypanosomiasis and how the history kind of followed, like, Muslim people who were--

DAHL: Yeah. So there are some parallels. The range of the tsetse fly, which 00:10:00spreads African trypanosomiasis, kind of parallels I guess the range of how far south the Muslim religion went. And it was kind of parallel to where horses could survive. A lot of the Muslim, I guess, conquest, or Muslim spread was due to people moving south on horses. And they could only move so far south because the tsetse flies would kill the horses. So if you kind of look where--in North Africa, where--about as far south as Islam goes, that parallels the range of the tsetse fly. So they are interconnected, and I always thought that that was kind of interesting, thinking, okay, the history--how history and religion and disease all were interconnected.

Q: Right. Absolutely. What kind of work were you focusing on with the tsetse 00:11:00fly? Epidemiologist kind of stuff?

DAHL: Yeah, epidemiology. It was really surveillance. There was a treatment, we were looking at drug treatment failure, and surveillance for that there. The treatment for trypanosomiasis is a pretty toxic, arsenic-based drug, and we were starting to see a lot of failures, and we weren't sure if it was resistance or what exactly was going on. But it's quite a toxic drug, and I think 10% of people treated with it die anyways. African trypanosomiasis untreated is fatal, so it has to be treated, but this drug, melarsoprol, was really toxic. There was a newer drug that was being advocated called DFMO [α-difluoromethylornithine], that was less toxic. We were kind of trying to do a comparison to see if maybe there would be some advantages to trying to push for DFMO. DFMO was a little bit more difficult to administer and it was 00:12:00definitely considered an expensive drug, but it probably had fewer side effects. There wasn't a lot of baseline information, though, so this project really was trying to get the baseline information to advocate for switching drug treatment therapy.

Q: Did you get that information?

DAHL: Yeah. Yeah, we did. There was a lot of that. I think in most places now, they're trying not to use melarsoprol, and they're trying to use this DFMO because it's less toxic. There are two types of trypanosomiasis. There's the gambiense, which affects most people--that's a longer, slower disease. And then there's the rhodesiense, which is more acute. That's only really in East Africa, and that still has to be treated with melarsoprol, just because of the slight difference in the parasite. But yeah, most people are now being treated with DFMO.

Q: Gotcha. And then--I'm sorry. I blanked. You next were working with which countries?

DAHL: So I guess--

Q: After 2009?

DAHL: After 2009, Democratic Republic of Congo, Cameroon, and Central African Republic. This was a project to try to improve surveillance in these countries. It was something that it was real obvious that disease surveillance was lacking. There was an example in Congo, where there had been an Ebola epidemic going on for about six months before it was detected. I think it's because it was in a really rural area, but it's still, for something that we know now, this should be so apparent. It went on for a long time. So this was a project the Gates Foundation funded with the idea of, okay, we can improve surveillance in these three countries. They're definitely challenging places to work, and they are a lot less developed than much of the region. The central African region, in general, is probably a lot less developed, and so the capacities there were 00:14:00definitely limited. But this project really was set up to try to address a number of issues. The one part that CDC worked on was setting up FETP, Field Epidemiology Training Program, a regional one. They wanted to train people from CAR [Central African Republic], from DRC [Democratic Republic of the Congo], and Cameroon. This was set up in Cameroon. They would bring students or fellows from each of the countries to try to build up the critical mass of epidemiologists that were needed. Additionally, we were working with the ministries to improve their surveillance capacity, so going out and doing some of the basic work that's needed. Going out to health posts or district-level areas to do the supervision, just see our people actually doing their work, do they have the resources that are needed, supplying some of the resources, just to show that maybe with a slight input of resources, that they could improve their disease 00:15:00detection. There were some anxiety, it was a challenging program. The expectations, I think, were maybe a little bit greater than what was probably possible in the time period. I think we've definitely made some improvements, and there were--even during the Ebola epidemic, I mean, we definitely touched on that. We touched on some of the human resources, recruiting a number of people that we trained from DRC to become part of our team in Guinea. I think we did see initial improvements in these countries related to surveillance. It also really showed the need for investments in surveillance to be really long term. It's something you can't say okay, here's some money, and then step away. You have to be really invested and committed, and realize it's a long-term commitment that's going to be needed.

Q: Right. Absolutely. How long were you doing this work?

DAHL: This was a five-year project. So that was 2009 through '13, I guess, or--yeah, '13 or '14, something like that. I think it ended at the end of 2013, so--

Q: End of 2013?

DAHL: Yeah.

Q: Okay. So you had time to do one more thing, maybe, before the Ebola epidemic?

DAHL: Yeah. I continued doing some work. I worked in the Immunization Division--Global Immunization Division. I also worked on some other diseases. Right before starting to work on the Ebola epidemic, I had been in Geneva for a couple months, helping WHO with some of their HPV, human papilloma virus, vaccine work. That was coming up with some of their documents and ideas, policy papers on how to better introduce the vaccine, because we know it can prevent 00:17:00cervical cancer, so helping countries come up with policy on how they would introduce it. Because the target range for that introduction is a lot different than what normal EPI programs are--EPI, Expanded Programme on Immunization. Normally, those are targeting children under five, and often, really just children up to twelve months, whereas the target for HPV is generally adolescent girls. So different challenges because it's a community you can reach, possibly through schools, but it's a different mindset from your normal EPI program.

That was in June and July of 2014. I got back to Atlanta at the end of July in 2014, and was contacted by Mike--Michael [H.] Kinzer, who was working in Guinea 00:18:00at the time, for the Ebola response. And he said, "Ben, we need you out here." I had just returned to Atlanta, so I wasn't sure if the timing was right, because I literally had been--I got back at the end of July, and that was right around the time that the EOC [Emergency Operations Center] was activated, and there was a call to get, I think, fifty epi--fifty staff on the ground in the three countries. I think I was probably number forty-nine or fifty. I mean, I was back two weeks and gone to Guinea to work there with Michael. Michael was the response lead at the time. We had a small team. There were eight of us. So it was really intense. Everyone was doing everything. The WHO regional response was 00:19:00centered in Guinea. There was a--they called it the Ebola Coordinating Center. It was based in Guinea because that's where the epidemic had started, and then also working on operations in Liberia and Sierra Leone. So the regional response was based out of there.

It's funny. Michael said, "Ben, I really need you to focus on this as a full-time job." He was supposed to be doing that, as well as really leading the response. He said, "I need you to do this. And just warning you: these guys from WHO, they're assholes." [laughter] He said, "They are just impossible to work with." I was like, okay, I have experience working at WHO. I know they can be difficult. It was not necessarily the best idea of going to work, but I knew the 00:20:00job needed to get done, and I trust Michael. So I arrived my first night in Conakry, and was picked up, got to the hotel, and Michael met me, and the hotel was deserted. It was a hotel, probably one hundred rooms, and there were maybe twenty guests, probably the eight of us from CDC and then a handful of people from WHO. But Michael said, "Let's go get some dinner." We walked out to the hotel restaurant, and all these people started coming up and hugging me, like, "Ben, Ben." [laughter] They were all these WHO people who I had worked with on this project in Central Africa. It all was tying together. They were all hugging me and saying, "Welcome. This is great." And they went back to their table, and Michael sat down and goes, "Those are the assholes I'm talking about." [laughs] He goes, "I think we'll be fine." So their mindset completely changed because 00:21:00they knew me. That's kind of how it works there. WHO is great to collaborate with, but at times, they can also get a little insular and not trusting of CDC. But we did break that barrier right away. That was one of my first memories, like, oh boy. [laughter]

Q: Oh my god. Did you learn French while you were in Central African Republic, or was it before?

DAHL: I learned it in high school. I learned it in high school, and I lived in France during an exchange in high school. So I learned it in high school, and then kind of got bored with it in college, so I took Spanish, and that's why I went to Chile, to work on my Spanish. But then going back, opportunities kept coming up to use my French, like this project in Central Africa was French. It was French-speaking countries. One thing I did find is that there aren't a lot of people at CDC that speak French. So that, I think, is another reason why Mike 00:22:00asked me to come out and help out.

Q: Sure. So can you tell me about the first few days on the job?

DAHL: Yeah. It was a lot of meetings. There were eight of us from CDC, and three of them were EIS [Epidemic Intelligence Service] officers. So we had just a lot of meetings. There were coordination meetings. It was kind of just getting an idea. Since we were the regional response, there was issues related to what's going on in three countries. We had a call, I think, every day with Geneva, and also people from Atlanta. So we would have that. There was also a national coordinating meeting that was small and chaotic and just not well run. It would go on for hours. It was really poorly run. It was people calling in from the field and being on hold for an hour or two. It was complete chaos, and really not a lot of focus, and for a few days was just kind of getting to know who was 00:23:00on the ground, who we were working with. The outbreak was by all accounts really raging in Liberia and Sierra Leone. We knew we had a problem in Guinea as well. There were cases, but in comparison--I guess the dialogue at the time was: Guinea is stable, the problem is in Sierra Leone and Liberia. And Guinea's kind of doing all right. What we saw on the ground was--okay, we said, no, there's a real problem here. We kept saying, okay, we need more resources. We need more people to come here. We're a team of eight, and you've got twenty or fifty in Liberia. There's a little bit of difference. We know that there's a lack of French speakers, but on the other hand, we need just more bodies. Because I mean, my job, I was working in this regional coordinating center, but I was also the point person for all the internal flights for all three countries. The World 00:24:00Food Programme had just set up a network of flights in the area, so you could travel from Guinea to Liberia to Sierra Leone. And because I was there, I was booking all the flights. So I remember--this was later--not later, but this was, I guess, late August. We found out that Dr. [Thomas R.] Frieden was coming with Dr. [Thomas A.] Kenyon and one other staff member. And we weren't sure how they were going to get to Guinea. So I had to go in and book them flights. I had to get their flight information, and we had to pick them up at the airport. And it worked. We had to arrange kind of a special flight for them, but it worked. The 00:25:00World Food Programme should be really commended for having that logistics, because we couldn't have done a lot of it without them.

Q: Was it the World Food Programme that ended up shouldering a lot of the flights between the region?

DAHL: Yeah. All of them. They really--yeah. So there was this program. They call it UNHAS [United Nations Humanitarian Air Service]--UN Health--I don't know, UNHAS. It's basically the organization that was the mechanism for flying all around. We had internal flights, as well as flights between the countries. In Liberia, I think, the US military helped pilot people around, but we didn't have that in Guinea. So we really had to advocate getting some air support, because Guinea is larger than Liberia and Sierra Leone combined, geographically and with population. So getting to the Forest Area driving would take two to three days in the rainy season, whereas you could get from Conakry to the Forest Area in an 00:26:00hour or two on a flight. That really changed the dynamic for us.

Q: Right. So they were flights not just between the country capitals, then, but also to the less-populated regions that --

DAHL: Yeah. It was an evolving process. Initially, there weren't any flights. Then working--that was one of the benefits of the coordinating center. We were able to assess what our needs were, and so we said, we need air support. There were the flights between the capitals, but then we said, okay, we need helicopter support, because there were some areas that just you--that no landing strips, so you had to be able to get around. We also worked on that. They did establish helicopter support, and later on that became a good tool for us.

Q: When would you say that went?

DAHL: I guess the negotiation for the air support really started in September 2014. No, it must've been August because we picked up Dr. Frieden in the 00:27:00beginning of September. The negotiation, we all did that in August 2014, and it started really pretty much after that, and it was pretty quick. I was impressed. I think they added flights as it went along, but the initial support was probably August 2014.

Q: Gotcha. I know one hot issue in Liberia ended up being whether the US military would transport, like, specimens, and that kind of thing. Or at some point, they would drop people off at an area where it was, like, a hot zone, but they wouldn't pick people up. How were things on that end for the World Food Programme flights?

DAHL: Yeah. There--similar descriptions. They would not transport specimens. That was clear in their TORs [terms of reference], that it was not for transporting specimens. They would return. They wouldn't just drop us off and make us hike back, like those stories in Liberia. So again, we weren't treating 00:28:00people, so I think that made it a little bit easier. But then they had regulations. Specimen transport was by road. At the time, Guinea only had two treatment facilities. They had one in the Forest and one in Conakry. With each of those facilities, there was a lab associated with it. It could take more than twelve hours for a specimen to get there because of the road conditions.

Q: Right. Somehow I think it's--I've been doing these interviews for a bit, and--there were only two ETUs [Ebola treatment units] in Guinea?

DAHL: Early on, yeah. There was one established in the Forest Area in Gueckedou, because that's kind of where the outbreak initially started. Then there was a transmission a little bit later in Conakry, so MSF [Medecins Sans Frontieres] set up a second one in Conakry. Again, the dialogue was that Guinea's stable, so 00:29:00they had the two. No one really else stood up to do it. So MSF, they were limited. They could only really man two facilities. We saw that there was a huge increase in ETUs, or we heard there was a huge increase in ETUs being set up in Liberia and Sierra Leone. Eventually, I think they got to maybe five or seven in Guinea, but that was a much slower process. But for the longest time, it was two. So that was also a challenge because you have to take patients so far to get to one of these ETUs to be treated, and it just led to a lot of issues.

Q: Gotcha. So going back to the first few weeks, are there any images, or memories, or people who stick out, in particular?

DAHL: I guess, yeah. Michael Kinzer, obviously, from CDC--we were a small group. Again, we had three EIS officers who had just completed their first training in 00:30:00July, and this was August, and they were out. So--

Q: And who were they?

DAHL: There was Negar Aliabadi, Rupa Narra, and Max [Maximilian] Nerlander. There was the three of them. We were just like, okay guys, we can't let you guys get sick. We were trying to see what they could do, and just coming up with tasks for them, but they were great. They would do what we told them, and I think there were some challenges and learning experiences for them, but they were wonderful. Then we had a couple other people. Lisa Moorhouse was also there, and she would do anything. She would run over to the embassy to get money for us, or would arrange car transport, or do health communications. Again, everyone had to do everything. We have a lot of different trainings, different backgrounds, but pretty much you had to do everything. I was a logistician, I 00:31:00was an epidemiologist, I was a diplomat, all those things. Then just meeting some of the local people. Especially, that was when I first met Dr. Sakoba [Keita], who ended up being the Ebola response coordinator. But at the time, the response in Guinea, as I said, was pretty poorly coordinated. And so there was not one person in charge of the response. Each ministry wanted to have someone part of the discussion. That really led to chaos, because there was a committee, and meetings would go on forever. Everyone wanted to say something, but no one really could take charge.

Probably one of the most important things is, Dr. Frieden came with Dr. Kenyon and just got a sense of the situation. I think initially, they weren't going to 00:32:00stop in Guinea. I think initially, they were just going to do Liberia and then maybe Sierra Leone. But then we said, okay, it would be good to have a visit and we--small group. It was great for us, and that was the first time I had ever met Dr. Frieden. It was a little funny. I think he looked around, he saw me, he saw Michael Kinzer. We were both probably a lot younger than the leadership and a lot more junior in our career than the leadership in both Liberia and Sierra Leone. And he was like, "Ah. Wow." [laughs] Again, he had confidence in us, but it was--also, it was intense because he did not have a lot of time and Michael was set to leave. He had been there I think for six weeks, and he was getting ready to go back. There wasn't really a good--there was a little--going to be a 00:33:00little break in leadership, so I became the response lead. But we were just kind of planning the meetings in Dr. Frieden's hotel room, right before they were getting ready to go on their way back to Atlanta. But I think the best thing about it is that having Dr. Frieden and Dr. Kenyon see the situation gave us, as an organization, a push for the country to restructure their program a little bit, so to really have it in the incident management structure. We really pushed a lot on that and had the president of Guinea agree that this needed to be done through this incident management structure that CDC would help support with WHO, and that then Dr. Sakoba would be named the lead. He did become the lead, and that was good for stability, good for his leadership. He had been the lead in 00:34:00the Ministry of Health [and Social Welfare] for their infectious disease branch, and so he had the technical background. He never obviously experienced Ebola before because it had never been there before. But at least he understood infection.

Q: No doubt. What was it like working with him?

DAHL: It was great. Again, it took a little time. I think one thing that limited CDC is we had people--one, we were a small team initially, but then, also, people cycling in and out. So Dr. Frieden was there, so it must've been early September. He asked, "Could I stay longer?" I said, "No." He said, "Why not?" I said, "My brother's getting married." He said, "Congratulations. When can you come back?" [laughter] I said, "Probably in two weeks." So that's kind of what 00:35:00happened. That ended up being my second deployment, two weeks later, in September. I was there in August, August into early September, and then back by September of 2014 for my second deployment.

Then Dr. Sakoba, seeing me a second time, I think started to build up the relationship. I ended up deploying seven times for the Ebola response. And so going back each time--and it was good. The challenge, again, as I said, was CDC was cycling in and out so much that--a lot of revolving faces. But I think that was probably one of the benefits that I could offer was having a level of consistency. So I think it also became a little bit self-perpetuating because each time I would go, then the ambassador or others would request that I go back. That ended up happening quite a bit.

Q: I can see how that would make sense to have the same point person with the 00:36:00same base of knowledge, versus somebody who's--I've heard quite a bit about cycling in and out, and people in countries saying things like, well, I don't know if I even want to work with you because you're going to be gone soon.

DAHL: Yeah, there was some of that. I think we tried to explain what our system was. Guinea, we had a lot of repeat deployers, probably because it was a French language that we needed to just get the same people back because there aren't as many French speakers here. But it also, I think, probably led to some burnout, because people were going back. A number of people went more than twice to Guinea. There were some people we wanted to come back a second time, and they wouldn't. I think one thing we often--there were others who observed this too. Usually, if it was a twenty-eight-day deployment, by the time you're winding down is when you're really getting a sense of what's needed. So I think, 00:37:00something that I could do is I could get back in the country and be up to speed after a day or two, or maybe never even really dropping off. I mean, obviously, the situation changes, but after a while, I just was never really falling out of the loop. Even though I was back in Atlanta, I was still staying up on what was happening.

Q: Right. How did you notice things change, once Dr. Sakoba was really in charge of everything?

DAHL: Again, it was a process. Something I think CDC really tried to help a lot with is just bringing a little bit more organization and bringing a little more focus. We tried to, like, have the national meetings not go for three hours and be open-ended, so really trying to focus that. That was definitely something we tried to push early on, because it was just--you can't have--we need to be working. We couldn't be just talking. Obviously, it's information sharing, so it wasn't a lot of blah, blah, blah. But at times, there were people who were just 00:38:00it seemed liked talking to be heard. I think one thing we tried to do was support him that way, and to just say, okay, this is how you better have a focused meeting with an agenda. It was a good dialogue with him, it was a new disease for him, and so we're trying to come up with different policies. We were all learning a lot. He was learning a lot, I was learning a lot, and our WHO colleagues were learning a lot. In terms of the WHO side, there was a while where I was cycling in with their response lead coming from Geneva or from Copenhagen. And so we were kind of on the same cycle. We kept referring to, like, season three, season four, and--yeah. So we did that. It's good. I think WHO's response also changed. I think initially, they didn't have the strongest people there with a lot of experience, but that all changed when it was named a 00:39:00public health emergency of international concern. I think they started sending better people from Geneva. So I worked really well with the leads who they had sent from Geneva or from Copenhagen. Those people had a lot of experience with Ebola, so that I think also helped. Our goal really was to support Sakoba, but we didn't want to take control. We didn't want to make this a WHO response or a CDC response. We wanted it to be a Guinean response, but with our technical backgrounds.

Q: Right. Who were some of those people, those leads from WHO who stand out to you?

DAHL: There were two that really stood out from the headquarters area. That was Guenael Rodier and William Perea. They're both experts. They're both wonderful to work with. We had a lot of heated discussions and, I think, different ways to look at it, but I think we had overall the same idea--what to do, and how to 00:40:00respond to it.

Q: Can you give me an example of a discussion that got heated?

DAHL: Well--I think there were some times just where--trying to come up with what was the best response. Like, how do you--initially, the response really wasn't rigorous, and they were not tracking down cases. They were responding. They'd have a case, but they were not tracking down all the contacts. And then you were just leading to more and more cases. There were maybe guidelines, but they weren't being applied. So something that we really insisted on is just being more systematic. Again, our team from CDC was pretty small, so we could offer advice, initially, but it was harder for us to implement it. We eventually did really scale up the numbers, but there were some of those times that it was 00:41:00a little challenging, and really kind of insisting for rigor. I think that's something CDC is good at. But at times, we were advising, but not being able to actually implement it. So that was, at times, challenging. And at times, WHO even challenged us on that, and said, "Okay, you're talking, but where are the resources?" But I think we worked really well with them, and we financially made it possible for them to do a lot of their response, and I think the trust was there, too. Because I mean, when I was cycling in and out with the same people, at least there was the same face. They knew that there was some consistency.

Q: Right. Were there ever any kind of like philosophical differences on how to handle the response in one way or another?

DAHL: Yeah. I think there--at times, there were. I think even having this kind of regional response, that eventually went away, but that was initially how WHO thought that they wanted to organize it. It led to a little bit of chaos, and I 00:42:00think we were wanting a little bit more focal response, just directed at the needs of the country. I think one thing we really tried to do, too--and this is as the epidemic went on, and it kept going on and on--but was making sure the data was used. There were definitely some differences around how to use the data, or who had access to the data. At times, we had problems with WHO with that, for them not wanting to share the data. I said, look, we're not here to publish articles. We're here to stop an epidemic. We need access to the databases. And there were some challenges with that.

Q: If you listen to Pierre Rollin, CDC has a reputation for wanting to focus on writing articles sometimes with the international community. Do you think that played a role? Like, did we come in with a reputation of--

DAHL: Yeah. I'm sure that played a role in some people's minds. I mean, I don't 00:43:00think there were too many--there probably are people that were continuing to think about publishing articles. But in Guinea, we weren't. We didn't have the time. We didn't have the staff. And that led to some of my hottest arguments with headquarters was they, for a while, were saying, you're not publishing enough. And I said, okay, we're working here. We're trying to stop the epidemic. And then, at one point, someone in headquarters said--they started sending a tally of how many publications were coming out from Liberia, Sierra Leone, and Guinea. So, like, they said, Liberia: fifth publication; Guinea: still at zero. And at one point, I just--I was, I think, on a call or something. And I kind of just lost it and said, "Look. You want us to fucking work, or do you want us to publish?" And that ended that conversation. Again, we need to document this, and we need--there's a huge importance of having that, but it just seemed, at times, headquarters was so focused on other things that were not our priorities.

Q: Right. I've had a couple wonderful conversations with Pierre. Were you working with Pierre pretty closely?

DAHL: Yeah, at times. Pierre was there earlier, and there were times where we overlapped, and times we didn't. So he was also there as response lead, and we would have some overlap. So we got to know each other. I didn't know him previously, but we--yeah, we definitely got to--I got to know him, and we would sometimes cycle in and out as lead. At the end, the last cluster in March-April 2016, we were both there pretty much the whole time together. That was great. I mean, we just--one-two punch. So that was great.

Q: Of course, you were mostly located in Conakry, but in the beginning, were you able to get out to the Forest Region? Were you traveling at all?

DAHL: In the beginning, no. That was something Michael and I talked a lot about. In the beginning, there was just--there was so much to do coordination-wise, and not enough people, we had to stay there. So I don't think I got outside of Conakry until my third visit to the country. Because we just didn't have the resources to get out. Just had to be there. We had staff out there in the Forest--but just didn't have the resources to get out there. So, trying to coordinate. Starting my third deployment, yeah, I was out in the field a lot. And that also was linked to having some more logistical support, so we had some vehicles. We had access to helicopters and planes so I could go out and just observe the situation. That gave me a better perspective, too. Obviously, I trusted the staff working for me out there, but it was nice to be able to go and 00:46:00support them.

A lot of this, too--and it was a lot--I think, as time went on, a lot of it, we were working very closely with the embassy, as well. The embassy supports the ambassador. Alex [Alexander M.] Laskaris was vital for the response, and he really played a huge role in the response, but also just visibility. Having an ambassador talking about this was something--he gave us great access to their president, and so that was something. President [Alpha] Conde, obviously, was very involved in this, and it was affecting his country, affecting their economy. So Ambassador Laskaris really facilitated that. It was a little bizarre, but it made me feel fortunate. I was briefing President Conde regularly. The ambassador said, "Ben, you're the Alpha Whisperer." Alpha--his name is Alpha Conde. And so they started just teasing me about that, 00:47:00because--and literally, he would--we'd be in meetings and he'd whisper to me, or he'd occasionally--I remember one meeting where the president--I'd already met with him twice in one day, and he sent a message saying I had to go to a meeting in the afternoon. I said, what is this about? I need to do some work. And it was a meeting where he just wanted to tear into the United Nations organizations, because he said they weren't doing enough. So UNICEF [United Nations Children's Fund], WHO, World Food Programme, all the different groups. Every time they would respond, he'd look to me and say, "Are they telling me the truth?" And I was like, oh god, this is a bad situation, because I was collaborating with these people, but they were also essentially not telling him the truth. Or they were sugarcoating things. And so I was like, oh god. This is a bad situation. But again, I was fortunate, developed a good relationship with him, with the president. He would pass things to me to say, is this true? And one example I 00:48:00remember quite clearly: There were a lot of people trying to profit off of Ebola. It was really disgusting, people wanting to make money off of the suffering. I remember there was an Italian company that was trying to sell the Guinean government mobile labs for Ebola, is what they claimed. They had a brochure, and it was very slick. They said you put this in every health facility, you'll be able to test for Ebola. That was one of our real challenges. We had two labs that were doing confirmation, so we know that the time from the delay could really lead to issues. So this Italian company somehow was trying to sell him--and I'm not a lab person but I've worked enough with labs to understand something. I looked at the document. It was complete--I don't know--huckery. It was just a sham. He was excited about it, because he's not a 00:49:00lab person either, obviously. But he asked me. I said, "Honestly, Mr. President, they're asking you for three million dollars. It's going to be a waste of your money." So he killed that. They didn't buy that. So I did develop a level of trust with him, and that was good, but at times, it was almost surreal. I got to where, okay, why am I talking to the president all the time?

Q: [laughs] That is really funny. I'm interested in that, because I can see how it would naturally happen, how people would start to sugarcoat things for a politician, when in reality, you want to be able to talk honestly and frankly about things.

DAHL: Yeah. I think that was probably one of the best things CDC was able to offer. Really, that started with Pierre Rollin, continued with Mike Kinzer, and with me, where we would tell the people--especially the president, who was very 00:50:00demanding--we would tell them what the truth was. And Pierre--I mean, you've met with Pierre. He doesn't sugarcoat things. That really bought us legitimacy. Even if we were smaller in numbers, it's something CDC had a very good reputation--and I think for a long time, the president didn't even know what my name was, but he'd just sort of--he'd look at me like, "CDC, what do you think?" And I would just respond. It was good. It gave us a good role, and it really bought us a lot of legitimacy that we still have, and a lot of goodwill that I think we just need to make sure we don't spoil.

Q: Do you remember any particular incidents where it seemed like people didn't want to really face the truth of what was happening, that you or CDC was able to describe it more bluntly?

DAHL: Yeah, there was a few different times, or just about policy approaches. There was definitely a time when, in Sierra Leone, they had instituted 00:51:00quarantines of villages for--if a village had a case of Ebola--military quarantine. I just didn't really feel that that was the right approach, and working with Dr. Sakoba, Dr. Sakoba also didn't feel like that was the right approach. The president would trust him, but he also needed someone to give some backup, and so we developed an approach that was a little bit more, I guess--I won't say compassionate, but a little bit more gentle. It was an approach that we called cerclage--it really came out of a community, where a new community had disease, and they said we don't--we had a big problem in Guinea where cases and contacts would flee. We even said, it was cases, contacts, and cadavers. People would transport bodies back to their village to be buried, and that was 00:52:00spreading a lot of disease. We had one community where we'd had a lot of people infected, and we said, "Well, what can we do to convince you to stay?" And the village chief said, "Build us a well and supply us with some food, and we'll stay." We kind of took that approach and then nationalized it, doing something called cerclage. We were able to convince the president that the approach in Sierra Leone wasn't the best. There had been a big meeting we were just at with the president of Sierra Leone and the president of Guinea. And the Sierra Leonean president was saying, "Look, this is the system. Look, we're responding with strength." And at the time, it looked like Sierra Leone's numbers were really dropping. So the president of Guinea said, "Okay, well, obviously, that's the right approach." And we didn't think it was the right approach. We can still debate or not, but I still think the approach we ended up developing in Guinea 00:53:00was an appropriate one.

Q: Did you play a pretty vital role in establishing the cerclage?

DAHL: I guess the formative area, but yeah. That was through discussions with Dr. Sakoba, and I was at this village visit when it really came out. This was really something that came up, a suggestion from the community. It was almost--I won't say an offhand remark, but it was almost a passing remark from the community. Saying, "What do we need to give you to stay?" And they said, "We want a well, we want some food, and we want some sauce." Some--basically just something to--in addition to their rice. So we just took this offhand remark and said, how could we apply this? We tried it there, and it was something that ended up being a really good collaboration with the World Food Programme because they were logistically charged with supplying the food, working with UNICEF, who 00:54:00was in charge of building the wells, and just kind of saying, this is how we can develop it. The idea was that we would supply the food, and then the villagers would have to just stay in their village. They could go to their fields in the morning, they could go to school, but they just had to be observed every morning and night. It was something to try to prevent people from fleeing their village, and that had been a real problem, where people were spreading disease all over the country because of that.

Q: When you say it emerged from the community, was this a particular meeting? What community was this in, where people were giving that feedback?

DAHL: We would--like, a small group--and sometimes they would really not be small--but would go to villages. This was Dr. Sakoba's idea. As the outbreak 00:55:00went on, initially, I think I said for my first two deployments I never left Conakry. And the same thing--Sakoba was rarely outside of Conakry. We really felt that if we want to address this--because the epidemic just kept going on and getting worse, or different--several waves of disease, and it seemed like each wave was getting bigger--that we really needed to be engaging the communities. Guinea had had a lot of problems with resistance, where communities would chase out surveillance workers or they would block the village so we couldn't access it. So the idea was that if we had a high-level delegation going to these villages, that maybe we could help ease the tension. So we'd been doing that for a while, and we were still running into problems. Like we were saying, people still fleeing the villages. So this was in one of those meetings. I think 00:56:00this was in--probably more in Central Guinea. I can't remember the exact town. But in one of those meetings, we--the villagers were gathered. They knew that there was a delegation coming, and we were just having a dialogue. Dr. Sakoba was very charismatic. He speaks many languages. And so he was really just explaining the disease, and then we wanted to have some back and forth and ask him questions with the villagers. And basically the question came out: What do we need to do to convince you to stay here? That's kind of how it started.

Q: Wow. Can we talk more about that issue of security? Were you in country when some of the incidents that were later reported in the media took place?

DAHL: Yeah. No, there was one--I guess probably the one that got the most press was when a delegation was going to one of the villages that had the disease, and 00:57:00they were killed. I think eight or ten people were killed, and that was horrible. I think it was probably a little bit more complex than how it was reported in the paper. I think there was--might've also been some score-settling going on that wasn't completely linked to Ebola. I think there might've been some of the local politics involved, but it was definitely linked to Ebola because the delegation that had gone to the town were going to try to open up a village that was resisting any Ebola intervention. But I don't think it was 100% related to Ebola.

Then we had other things. Villages were closed, they would not let people--not let our health teams go in. That was definitely one of the things that was always on my mind was safety of our staff, because we can't send people into 00:58:00situations like that. I think it was also challenging because our staff in Guinea was so limited that, at times, we had to have a single staff member in a place by themselves. Maybe with a WHO colleague, but we really tried to have CDC teams paired, at least for emotional issues and just for safety, but we couldn't. A lot of times we had people by themselves. We'd check in with them nightly, or have someone on my team check in with them nightly, and just trying to check on their welfare, but that was always something. Villages could change just so quickly, and you could have a situation where it was calm, you were going door-to-door, and then a group of agitated citizens would quickly change. It could become very hot and dangerous. I remember one of my team members was 00:59:00chased out of his village. They were being chased by people on motorcycles with machetes. Fortunately, the driver was amazing and did some evasive driving, but stories like that really always weighed on me, and just wanting to make sure that people were safe.

I think one thing we were also challenged with in Guinea, just the size of the country. There wasn't a lot of time allowed to feasibly have people come back to Conakry for some R&R [rest and relaxation]. We heard that that's what would happen in Monrovia and in Freetown, that if you were out in the bush, maybe you'd come back on a weekend. But if someone was in the Forest Area and it's two days away, you couldn't really just come back, especially if it's a twenty-eight-day mission. It's like, okay, sorry, but you're going to be out there for twenty-six days, and we'll get you back before your flight, but it--so that was something that--the teams that were really out on the field, they 01:00:00sacrificed a lot. It wasn't for everybody. We had some people that did great jobs, and who really thrived out there, but then others who just couldn't hack it.

Q: Were there any instances that you could describe in particular, where you had to weigh the need for people to go in and be part of a response for Ebola--like, the need in this community is so great--versus the safety issue?

DAHL: Yes and no. Safety was always our number-one concern, so we weren't going to send someone into a situation that was dangerous. If anything, it was having to talk to the staff and walking them back, because people were I think so committed, they maybe couldn't see that the situation--because they were there. They knew they wanted to do something. And we'd have to say, look, I need you to stay in your hotel today, and just let the situation calm down a little bit. 01:01:00That was something that, from my role, that we could do. Kind of see a little bit of perspective, because people would get so focal on what was happening locally, and they might not understand the overall situation. We'd talk about that and just say, look, you can't sacrifice your safety, because that would sacrifice the whole mission, and if someone had been hurt, it would really restrict us. The embassy was really supportive in letting us do our job, and should be commended for that, because they said, look, we know there's a job for you to do here. We know that you're adults and you're professionals. Don't put yourself at risk, but we're not going to say you can't leave Conakry, because that's not where the problem is.

Q: Who was someone who was dedicated in that way, you know?

DAHL: There were so many people, really, that would do a lot. I mean, being out 01:02:00in the field. And there were people who spent a lot of time. We had one guy, Jacob Dee, he was out in the Forest Area in one town, Macenta, when that was kind of the epicenter. And he--just, he would do what was needed. There are so many people like that. So hard to really just pull out one. Really, I think the majority of people who came out were dedicated, and at all different levels. Also, the whole response really did evolve. As I said, initially there were eight of us, and we were all doing just everything. And then it did become a little bit better, as we tried to set up a little bit more standardized protocol, so we eventually--we got a logistician. We got a guy, Jim Walsh, I 01:03:00think, was our first logistician, who just helped set up some order. He came and just really would help coordinate things.

We started setting up teams. Initially, it's just everyone did everything. But then we started having teams, and we had an epi [epidemiology] team, we had a team working on infection prevention and control, we had a health communication team. So we started having teams and it had a little more structure, once we started getting the critical mass of staff that we could actually do it. So there was some of that, that really brought some order. One thing we also saw is that we would start even trying to recruit people to come back when they were getting ready to leave. Again, most people were great. There were a couple people that probably should never be allowed to leave Clifton Road, [laughter] but for the most part, they're pretty good people.

Q: Good. [laughs] Yeah, I'm interested in that evolution. Can I--let's pull this back a little bit. You said you had, like, seven or eight deployments in total?

DAHL: Yeah.

Q: Your second deployment started near the end of September?

DAHL: Something like that, end of September, 2014, for a month.

Q: About a month?

DAHL: Yeah. Maybe five weeks. I--the deployments would range between four and six weeks, each deployment. A little bit of a blur, but--yeah, so they would be about that.

Q: And then how long would you spend back here?

DAHL: Well, it became kind of--as it went--I initially--I didn't think I was going to go back after the second deployment, but I did. I can't remember if that--it's a blur. I know I was there for New Year's Eve of 2015, so I probably 01:05:00got back to the country the day after Christmas or something like that. I can't remember if that was my--that must've been my third deployment. I can't remember. But again, that was probably about a six-week deployment. It was kind of at a little low--I think there weren't a lot of cases, but it was also a weird period because it's the holidays, so a lot of people are taking time off and--but that ended up being an interesting deployment because CDC had made this big push to have care packages sent out to the deployers. So we got our care package, I think, a few days after Christmas. There was just so much stuff. It was crazy. There was a Christmas tree--I guess one of those plastic Christmas trees, so much beef jerky. I've never seen--like, it was a just ridiculous amount of beef jerky and candy, and so many things. It was just--it was too 01:06:00much. It was almost disgusting. But it was wonderful. It was so appreciated because we needed it, but it was just--some people just definitely overdosed on candy and beef jerky. David [L.] Fitter definitely--I found out--he was a guy who deployed many times, and he--great guy, but I've never seen someone eat so much candy. [laughter] It was almost obscene. But that deployment was a good one because we had a solid team in place and we had a little more order. I think that was the first--I had a deputy for the first time, and that really made a difference.

Q: Who was your deputy?

DAHL: Miranda [R.] Bodfish, and she was one of the best people I've ever worked with. We ended up also deploying several times again together, but she was just--it was amazing how in-sync we were. Thinking about the same things. She 01:07:00was checking up on the team. We'd be emailing each other. I'd send an email, thinking she wouldn't read it, until the next morning, I'd send her an email, like, at 2:00 am, and she'd be responding at 2:01. I was like, okay, this is ridiculous. We should be sleeping. Sleep deprivation was definitely one thing we saw a lot of because, responding to, obviously, in-country needs, so you have to be up at 6:00 am, and then Atlanta responses and requests. You had to basically just--always glued to a BlackBerry. There were so many calls with Atlanta. Just kind of being in a different perspective. Kind of jumping around, but I remember--this was after Dr. Frieden's first visit in-country. There was a little transition period. I was getting ready to leave. My replacement was getting ready to come, but it was going to be very [limited overlap]. And so Dr. 01:08:00Frieden wanted to talk to my replacement. He thought he was there, but he wasn't. So he said, "Okay, can I call you?" It was going to be just one of these big calls. So I sent him my number, and my phone rings, like, literally thirty seconds later, and he says, "Ben, it's Tom." I'm like, oh, god. [laughter] I had met him previously, just a couple days before, but it was just--it was kind of bizarre. You always had to be glued to the BlackBerry because if there were [an emergency]--it's just so many messages, but you learn to triage. Like, if this is coming from Dr. Frieden, then obviously you need to respond. If this is coming from Barb [Barbara J.] Marston, you need to respond. Other people, you maybe push it down a little bit. Atlanta got upset at times, like, okay, why haven't you responded? But it's like, well, there's just so much going on.

A great memory for me of why wanting to always be glued to it: We just had a team meeting. We'd have team meetings late, at the end of the day, so--but it's 01:09:00probably about seven o'clock or eight o'clock, local time, and got an email, said, "Gather your team for a phone call. One phone line. There's going to be a call with the White House." And I said, "Okay. Let's see. Everyone, let's gather in my room." I wouldn't really know what this is about. We thought maybe there was just going to be a pep talk or something. But we thought it was really related around Atlanta, because I'd seen an email earlier in the day, saying, "If you have any questions you'd like to ask President [Barack H.] Obama, send them." But we thought that was--okay, that's just Atlanta stuff. He had been to Atlanta I think a month earlier, or at some point in mid-September, so this was probably early October, late September. And I gather the team around, and they 01:10:00said, "Okay, dial this number. No press." I said, "Okay, fine. We're on." Telecommunication was always a challenge. We dialed the number, and then it was just dead air, and we couldn't tell if we were still on the line, and then had our whole team around. And then they said, "Okay, the next voice you hear is going to be the president of the United States." And it was--the timing was great. It was kind of a pep talk. He was just thanking CDC for our effort, and just for everything we were doing. And then there was one of these questions from Atlanta, some EIS officer reading it like a robot. And then the EIS officer sitting next to me--we were on mute, and I was like, "Who is this chucklehead?" If you can have someone ask the president a question, don't have them reading a script and sounding like a robot. It was like, that person should be fired. We were laughing, joking, just teasing. And then the person ends their question, and the president answers, and then the next thing I hear, "We'd like a 01:11:00question, comment from Dr. Ben Dahl in Guinea." I'm like, oh, crap. You could've at least warned me. We thought it was just going to be a pep rally. So I asked him a question. He'd obviously been briefed on the situation. He was asking about what were the French going to do. And I said, "Well, they might be trying, but we're not going to wait around. We'll collaborate with anybody, but we're not going to wait around for others to step up." I said, "We're a small team, but we'll do that." And he was like, "Oh, I like that can-do-it attitude." And so that was--to me, that's one of my--probably my best memories, or one of my biggest memories, talking to the president. And then they asked Frank [J.] Mahoney in Liberia to ask a question. And I swear, it was late at night, so I 01:12:00think he might've had a couple beers in him. He was going on and on, and cut the president off a couple times, and it was classic. Frank, he's one of our stars here. He knows so much of what he's doing. But I was amazed, though. Frank probably talked for about three, four minutes. And the president was able to synthesize it into a fifteen-second--what the needs were. And he said, "Let me just ask: Is this what you need, and this what you need?" And that was it. It was like, wow. This guy can really get it.

Q: Dang. [laughter] That's awesome. I've actually--I've heard Dr. Frieden refer to the long-winded Frank Mahoney talk to the president, too. [laughs]

DAHL: Yeah. Yeah. So I knew some people who were in Liberia at the time, and I emailed them, and I was like, "What was going on with Frank?" [laughs] They said, "He was hosting taco night, and we were drinking some beer." [laughs]

Q: Oh. [laughs] Let's remember there's a human component to all of this.

DAHL: Yes, yes. [laughs]

Q: People are trying to maintain their humanity.

DAHL: Yeah.

Q: I'm interested in that kind of bifurcation of, you know, we have to deal with the things that are in the country, but also have to respond to Atlanta. What kinds of things are you hearing from Atlanta?

DAHL: Lots and lots of requests for data. They obviously are reporting up to different people, and understood that, but a lot of the time, it just--everyone had their priorities. Looking at how it was structured here, there were so many teams in Atlanta, and then we were pretty small in the field. You had a health comms [communications] team. You had all these people in Atlanta. They each wanted their data at that moment, or their request answered at that moment. It became a little bit--just too much, at times, because it wasn't reflecting our 01:14:00reality. Or a lot of times, the requests--they were well-intentioned, but someone got an idea in their head in Atlanta that this is what was needed and kept going with it. Or maybe it was a project that had started a while ago and that someone wanted to continue to work on, or they thought that was where the priority was. But the situation in the field was so fluid that, yes, maybe we--there were times, I know, that I said, "Okay, we need this." And then I would go back a few months later, and that's when they'd be addressing it. And it's like, okay, well, that's what we needed in October, but now we're in December, and it's--or January, and it's a different situation. But some of these requests, either from the field or from Atlanta, some of them just wouldn't go away. So there was that. We would try to be respectful, and respond if we could, but--

Q: Is there one that's kind of infamous for you in your memory that wouldn't go away?

DAHL: Well, we had to come up with projections of how much staff we needed, and so we were making this stuff up kind of as we went. I think we set a number, saying, okay, we need seventy-five staff in country, because we knew there were going to be like one-hundred-and-something in Sierra Leone. And somehow that number just never--I mean, that was the target, and that just [never went] away. Atlanta was always trying to recruit people because they wanted--they were told that they needed to hit that number. We were always kind of under that. Even as the epidemic went on, they were trying to hit the number. We said, actually, we don't need that number. We need a lot fewer. We just need better people, or quality people. And so there were some things like that. But a lot of it--again, we were just--I won't say making it up, but just learning as we went. I remember 01:16:00early on, I had to place an order for body bags. I had never ordered body bags. I said, okay, we need five hundred body bags. And they shipped them, and we had body bags, but I guess most body bags are black, and so these are black, but because of the Muslim culture, they wanted white body bags. And I was like, okay, that's something I would never have thought of. It was like learning those sort of things. So then we had to order more body bags and make sure that they're white body bags.

Q: That's a pretty sobering thing to do.

DAHL: Yeah. That's another thing, too. I can think of a few different memories that probably will last. Obviously, the conversation with President Obama--but yeah, ordering body bags. That's not going to go away. That was definitely haunting. Yeah.

Q: Can I ask, also--I know that you discussed being part of starting these 01:17:00epidemiologist training programs, FETP, in--I think you said DRC, Cameroon--

DAHL: And in Central African Republic.

Q: --and Central African Republic?

DAHL: Yes.

Q: Did anyone who you trained, who you actually knew well, or even just an acquaintance, come into Guinea and--

DAHL: From DRC. That was actually, yeah, something that worked really well. Thanks for reminding me. Yeah, in DRC, we recruited a number of FETP graduates or FETP current residents. There were a number of them that I had personally trained a couple years before. So it was nice to see that because we're trying to build up this capacity, and to see that--one, that addressed our lack of French speakers, so we had people coming in from DRC who were probably better than most of our CDC staff, in terms of understanding the field. These are 01:18:00people who are district health officers. I think initially we recruited five of them, and it was working so well. I told Dr. Frieden, I said, "Look, this is great. We need more of these people." So that just kept going on. It was great seeing some people that I had personally trained, or seen people going back. A number of them deployed several times, That also should be something, I mean, that--and some of Dr. Frieden's visits to DRC, he's spoken with them. It's something, though, that was a great collaboration. It was also really important for--I mean, it was important for DRC, and also for Guinea, because it was a real South-South collaboration. I was in a meeting once and it was brought up. They said that they were really happy about that because they said, it's great. We appreciate you coming from the US, but it's great to see, though, that we can 01:19:00have African-African collaboration for the response.

Q: Absolutely. Were there any individuals especially who stand out for you?

DAHL: Again, there were a lot of different people. I guess one guy, Leopold, was always great. He was just a little, shorter guy, but he was just always smiling, he would just do everything. Just a lot of people. The Congolese didn't speak much English, so it meant--we'd have our weekly team meeting, and so we'd either have them just in French or have them be bilingual because they couldn't follow. But we also had our deployers. As the response went on, we had deployers from the US who didn't speak French. Initially we only had Francophones, but we could get by with some support staff who really were more about handling the 01:20:00operations that didn't need to speak French. And so we would have to have meetings in both French and English.

Q: Gotcha. So how do things--can you kind of describe your last few deployments for me?

DAHL: Sure. So I think after my third deployment, I don't think my office here wanted me to go back. They said, enough, enough. You've been gone a lot. You're a team lead. You need to do your job. And I said, well, that's fine. You're my boss, you guys can choose this.

Q: Remind me what office that was again.

DAHL: Global Immunization Division. And then I think the epidemic just kept going on, and I think they were having a hard time finding people, and so I think there was a request again that I go back. Initially there was some 01:21:00pushback, but I think it went up a higher level, from the director's office saying, okay, we need Ben to go back, and so I did. After that it just--I was getting name-requested by the ambassador, by the president, and it was hard for my office to say no. I think they realized that it's probably better just to send me, and then maybe the other people in the office can just keep doing their job, and they won't get requested. Because they--the home offices really were hit with these things. There's so much work that either was getting slowed down or not done. So there's some challenges there.

I think after that, my fourth deployment, was also--Dr. Frieden also came, was there. He came with Dan [Daniel B.] Jernigan and with Inger [K.] Damon. Pierre 01:22:00and I were in country at that same time together. That was an intense visit because Guinea was having a lot of problems at that time. I think the dialogue had changed from Guinea being stable to Guinea maybe being the area of most concern. And so--

Q: And this, I think, is March 2015?

DAHL: Yeah, March 2015. It was supposed to be a few-day visit. We had a lot of meetings set up, a lot of site visits to different areas with the team, with Dr. Frieden, and Inger, and Dan. It was great. For me, it was kind of like a--I won't say easy visit, because it's always intense and a lot of work, but I had arrived maybe three days before they did, so I didn't have to do all the logistical planning, getting ready for them, so I was able just to dive right in 01:23:00and just have the crazy-long days. That was a really interesting visit. It ended with--I think we had a four or five-hour-long meeting with President Conde, and it was intense, it was great, it was very frank. Dr. Frieden's French really improved during the outbreak, too. He went from knowing Spanish and speaking a little French to--during the first visit, we had a lot of translation for him. But then, I think during that meeting he was understanding 80% of it. If he missed something, then we would just say, okay, this is what he missed. But then there was a French--I think Air France was on strike or something that day. So we got a bonus day. [laughter] It was great because then it allowed us to 01:24:00refocus a little bit. Any time he came out, it really inspired the team because it's nice to have your director talking to you. It's intense, but it was great for the team.

Q: What were some of those intense conversations about, just briefly?

DAHL: Well, like, why are we continuing to see transmission? One thing that often came up: Why do we have so much community resistance? Why are these communities refusing access? Or why are people fleeing? We're trying to enforce burials. You weren't allowed to transport cadavers back to their home villages. That's something that really is important in the culture there, but we knew, if you were transporting an Ebola corpse, you're going to probably transmit disease 01:25:00with it. Or with contacts fleeing. We always had to come up with solutions for that. But the Guineans, they're just so creative for getting around these checkpoints. I mean, we had one. It's kind of sick, but someone had died of Ebola, and they were trying to take him back to his village, and they basically propped the corpse in between two people in the back of a taxi, and they were stopped at a checkpoint. Everyone has to get out of the vehicle to get thermoflashed, and obviously the corpse can't. And they said, "What about that guy?" They said, "Oh, he's sleeping." And they thermoflashed him. And obviously he's dead. [laughs] The police were upset. Everyone was upset. They said, "Okay," to the two people. "You're going to have to sit in the car with this guy overnight." But we heard about that. We were referring to it as our Ebola 01:26:00Weekend at Bernie's incident. [laughter] But it's like, oh, gosh, everything they would do to try to get around it.

I think one thing that it really showed to me, too, is just how mobile people were. This last cluster of cases, we had a contact who was a missed contact, who used an alias and fled to Liberia. That's why we had three cases in Monrovia. It was a woman with her children, and she died, but she--it was like, okay, she was in the Forest Area of Guinea, and got all the way down to Monrovia. Then we had other cases like that, and just people moving huge distances, either knowingly ill or not. And there was a lot of misinformation, too. I can understand why 01:27:00communities were scared. Because as I said, for a while, there were only two ETUs, so if you were sick, you had to be transported somewhere. And basically, if you were in an ambulance--I mean, early on, the fatality rates were so high, because people were seeking treatment late, that they'd pick someone up and then they'd never see them again. So communities became very resistant to that. We tried to address that by--again, making it up as we went along, but like, supplying phones so that they could at least talk to somebody. Then if--it was always best, if someone actually did survive, then they would go back to the village, then see that not everyone's dying. But a lot of the times, people--we had really high fatality rates early on.

Q: Were there issues that you personally had some say in? Were there--well first, were there issues with stigmatization of survivors? And then, were there 01:28:00any efforts that you were involved in to try and address that?

DAHL: The survivor issues are definitely something we talked a lot about, and it's something we were interested in, and trying to come up with policies. We helped put on a survivor conference to deal with issues--like, okay, how do you deal with stigmatization? How do you deal with providing services? There were so many stories you hear about someone getting Ebola, and then their landlord saying, "You no longer can live here"--being evicted. Or communities not wanting that person in there. And trying to explain to people that actually no, these survivors are safe. They're the ones you want to be around. But it was challenging. So many situations, too, where it was just tragic, because then 01:29:00you'd have four or five people die in one family, and then a survivor, and it could be just a child. What do you do with an orphan? Or it could be a father or mother who's lost their entire family. And they're asking, well, why not me? What am I going to do? I have no one. It's just definitely, really disheartening to see that. We're trying to come up with [ways to address] it, but the mental health services are already limited and lacking there, so just trying to come up with some different services there.

Then as the outbreak went on, we also learned more about the role of sexual transmission. I think the initial literature was that maybe you could have the virus circulate in the semen for maybe up to ninety days. Or I think initially, we thought forty-two days. Then we're finding more and more that--this last 01:30:00cluster in Guinea, from March of 2016, the person had been infected in November of 2014. So we're just finding out so much. But it just changes things. So we did a project to really try to map where all the male survivors were, just to get a better idea about, do we test them, or what can be done. For the most part, people do clear the virus, but we're finding out that not everyone does so quickly.

Q: Right. You're mapping the male survivors? Can you tell me more about what has become of that?

DAHL: Yeah. So I think there's a--not a project, but some services in-country. We basically have an idea where most people who had the disease lived. Because 01:31:00of some of the evictions and things like that, not everyone was in the same place where they had been living before, but most people are more or less in the same area. So the idea was to track down all the survivors and, for the male ones, try to test their semen. That was a collaboration. CDC was involved in that, and there were some French groups doing that. Trying to just come up with an idea. This is where CDC played a bigger role, was more coming up with the policy or the idea of that. Working with Dr. Sakoba, saying, this is something that needs to be done, that we need to really try to do this testing. Then I think there's also a desire--Guinea was also the place where the WHO tested their vaccine, and they had a ring vaccination strategy to do that. The idea 01:32:00would be to vaccinate the close contacts of these male survivors so that if these people had not been infected, there would not be the chance for sexual transmission.

Q: Has that gone on, then?

DAHL: Yeah. It's going on, in little fits and starts. But yes, it is going on. It's a challenge because we're dealing with a vaccine that is still a trial vaccine. I think the initial paper that WHO published showed that it was fairly effective, but still, it's not--it's a non-licensed vaccine, so trying to do this out of compassionate use. And there's a lot of different protocols that way.

Q: Can I also ask, just a clarifying--when did you have the survivor conference?

DAHL: Sometime in early 2015, like in the first half of 2015, so maybe June of 01:33:002015. I can't remember exactly.

Q: Gotcha. Was this a public thing, or who did you invite?

DAHL: Yeah. It was something that was put on by the Ministry of Health, WHO, UNICEF. We invited people from--there were some representatives from survivors groups, also just people involved in the response, to come up with, like, a survivor strategy.

Q: Cool. So I know you were most recently, then, in Guinea in March and April. Is it over for you, being part of this Ebola response? Or how do you envision being part of Guinea or West Africa from here on out?

DAHL: Yeah, good question. Yeah, I'm hoping that it's over for the Ebola 01:34:00response. I'm hoping that there are not going to be more cases. Obviously, if there were a cluster of cases, I probably would go back. If they asked me to, I would go back. Working in West Africa--and I do work there already. There's Global Health Security Agenda work. Guinea's one country that I cover. I am the immunization focal point for the Global Health Security Agenda. On my team, we do a lot of work in the area. So I continue to go for that. I also--March, April was supposed to be just Global Health Security work. It wasn't supposed to be Ebola work, but it obviously changed. You have to be flexible. But yeah, I would imagine I'll be back to Guinea, but hopefully not for Ebola.

Q: Gotcha. So as we look over your entire part in CDC's Ebola response, is there 01:35:00anything we haven't talked about that you'd like to share? Any memories, or basically, anything that you'd like to reflect on about your work in the response?

DAHL: I think we've touched on a lot. One thing, it definitely became--obviously, just how many good people we have at the agency. And for me, it was--I'd say so far, it's definitely the--I won't say highlight of my career. It's been the biggest thing of my career. I had an opportunity to work with people that I wouldn't have had otherwise. It definitely opened me up to a whole group of people outside of my normal work colleagues. So many people were involved, and I think it's because I went so many times, I still run into so many people here on campus that I see that had been deployed with me. Then 01:36:00professionally, it gave me opportunities to work with people very closely that I wouldn't have. And I wouldn't have had the chance to work with Dr. Frieden at the level I did. I wouldn't have had the chance to be talking to President Obama, or--I mean, a lot of the people I've worked with, I wouldn't have had these opportunities if it had not been for that. But yeah. It's also exhausting, too. I was talking to Barb Marston about that just before coming to talk to you. And it's not over. Maybe the epidemic is over, but there's just so much work we still have to do. Now we do have to try to work on these papers that they were keeping score on before, and we need to really get some of this out, because we've learned a lot. So I think we need to make sure that when there's another 01:37:00outbreak in some area that some of the positive lessons learned can be applied, so we don't have to make it up as we go.

END