Global Health Chronicles

Craig Manning

David J. Sencer CDC Museum, Global Health Chronicles


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Craig Manning

Q: This is Sam Robson here with Craig Manning as part of our CDC [United States Centers for Disease Control and Prevention] Ebola Responders Oral History Project. I will be interviewing Craig about his experiences in the West African Ebola epidemic of 2014 to 2016. Great to have you here, thank you so much, Craig. Could you tell me the full pronunciation of your full name and also your current position with CDC?

MANNING: I'm Craig Manning and I am the health communication specialist within CDC's Viral Special Pathogens Branch. We're the branch that's responsible for studying Ebola in any of its aspects, including outbreak responses.

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

MANNING: I was born in Massachusetts in the town of Randolph, which is just outside of Boston, in 1951 on July 16th.


Q: Did you grow up in Massachusetts?

MANNING: I grew up mostly in Massachusetts. My family is from around Boston. We traveled because of my dad's work and that meant we lived in a number of states in the US, including Iowa, Texas, Pennsylvania, Florida, Michigan, and then once I was out of high school and on my own I continued to travel.

Q: What did your parents do?

MANNING: My dad was an electrician and he was doing large-scale, industrial-sized engineering projects, which might mean for example converting a coal-powered electricity generating plant to run on something else. Very much a kind of engineer, but also a teacher in his approach to things and very much a 00:02:00significant influence on my life in terms of how I organize information.

Q: Was your father the only parent in the household?

MANNING: My mom--I had a mom, like many other people, and I have a sibling, Meredith, who is three years younger than me.

Q: What kinds of things were you interested in growing up?

MANNING: I discovered guitar at the age of twelve and there was never any looking back. That's been a centerpiece of my existence from that particular time. That was, and remains, a grounding space, a private space, an expressive space or creative space for me to work in. By the time I was in grad school studying ethnomusicology, which is the music of basically other cultures or the study of music in culture, somehow I had a foreboding that it would indeed be 00:03:00part of my career. Certainly as a professional musician, on occasion, but also in my working career here for example. It did indeed have a role to play later on in my first Ebola outbreak in '07, where we were making radio spots for an Ebola outbreak in Uganda and we needed some music and I invited local people to help that process along with respect to conveying health messages using music. I was thinking back to my professors during my time in grad school, thinking, this is what you trained me for and I'm so grateful that you did.

Q: That would probably be the Bundibugyo outbreak?

MANNING: Exactly, in 2007, it was my first outbreak. I had been newly hired at CDC the end of June of '07 and I was in the field responding to an Ebola outbreak right around the end of November, beginning of December, so not a whole 00:04:00lot of time to get plugged into CDC before being shipped out to what was in some ways the warmup outbreak for what became the West Africa outbreak, for sure.

Q: Thank you for that. You were of course passionate about music from an early age. Did you want to do music as a career when you were, say, a senior in high school?

MANNING: No, I was not clear at that point what I wanted to be doing. I ended up being an anthropology undergrad because I thought that there was a way to understand humans in culture that was rather--that that piece of it was missing from my upbringing. It was not to be found in any sort of religious education and I thought it might have been findable in academia, and it did allow me to understand the diversity of the human experience, the way people parse the 00:05:00world, the way assumptions are made in one culture about the way things operate in another culture, and then that of course got stood on its head eventually. It's not that difficult to connect dots going all the way back to that point in time, or if not before, to the outbreak in West Africa where one of the cardinal operating assumptions that I was prepared to make and which indeed proved to be valuable was that you can't expect things to work in this place as you might have expected them to work in the place you are from or even necessarily as they worked in the Ebola outbreak in Bundibugyo in '07. It's true that maybe not all bets are off when you start a response, but many bets are off when you start to respond.


Q: Is there like an origin story with why you're so interested in other cultures and bridging them?

MANNING: I had from early days in my youth, if not my childhood, a strong sense of the relativism of the country into which I was born and to the ethnicity into which I was born, into the language and into the patterns into which I was born. Whether that came about organically or whether that was something to do with how I was parented or whether it had to do with just watching TV, I'm not particularly clear, but I was very acutely aware that it was important to understand how different people are from one another, even within a family, and that just seemed to extend beyond to friends, beyond to community, beyond to 00:07:00nation, beyond to the world. It was not of interest to me to necessarily observe distinctions or contrasts, so much as to try to acknowledge them and take this in as part of the larger understanding of what it means to be a person on Earth at this time. There's no religious orientation to that necessarily; it's merely a hunger on my part to understand how it is we can have just diverse expressions of our collective humanity while at the same time noting that there is this bond that enables us to find common elements and to unite when we have to in the case of overcoming something like an outbreak of Ebola in West Africa. So you go into that, at least I go into that, thinking, what an amazing opportunity to see how we can do under very demanding circumstances with people who know very little 00:08:00about us, and of course we know very little about them, but we've got to make this work. And there's a screaming urgency behind getting that part right, without stepping on toes, while at the same time not wasting time.

Q: You actually grew up in an era then with a renewed interest actually in other cultures I suppose. The sixties, an interest in Eastern religions, and Native American culture becoming almost faddish with the popular culture. That must have had a big influence on you as well.

MANNING: I hadn't thought about it as necessarily--that view that I've just been elaborating as being precipitant of the sixties. I suppose it very well could be. I think in my own instance, I was pretty directed just by the influence of 00:09:00my father and his real curiosity about the world. He was certainly in his day job as an electrician, but he was also a musician. He was also an accomplished artist who worked in pastels and oils and acrylics and chalks, and he did great work and it was valuable. He was a very capable teacher who was able to illuminate complicated matters and allow someone who is younger to sort of build the constructs that would enable the younger person, me in this case, to better understand what it was he was trying to say. So he made complexity seem manageable, seem comprehensible, and looking at how I take in the world now I don't know whether it's so much to do with what might have been happening in the sixties because I think I was one foot in and one foot out with respect to that, 00:10:00but later on academically and just psychologically it seems to be that inclusivity that he was so readily able to explain; that to me was kind of the touchstone.

Q: Where did you go to college again?

MANNING: Undergrad was to the University of Massachusetts in Amherst and then graduate school was Indiana University in Bloomington, Indiana.

Q: Did grad school come soon after undergraduate?

MANNING: Yeah. There was a year of pause in there where I had to inhale the real world for a time. [laughter] Really realizing it wasn't--I had to go back to grad school. It wasn't going to kill me if I didn't.

Q: Oh no. What was grad school like?

MANNING: Grad school for me was everything that I hoped a rigorous academic 00:11:00program would be. Plenty of freedom of choice, plenty of talented, motivated people. In some respects, that whole environment is very familiar here at CDC. It just feels like an extension of graduate school. The workload was enormous. The demand was incredible. You learned how to write. You learned how to use your time. You learned how to think, of course, and you learned how to be productive and create new--to do new thinking about things that had not necessarily been thought of just yet. In my case, in the world of ethnomusicology. The demand for--the bar was set pretty high and something in me just really thought this is the right place for me. [laughter]

Q: You mentioned when you were in Bundibugyo, fast-forwarding to the future in 00:12:002007, looking back and realizing, I'm doing what these professors had taught me to do. Are there some professors or one in particular who stand out to you as big influences?

MANNING: Yeah. There was a professor at IU [Indiana University], his name was Alan [P.] Merriam, and he taught Intro to Ethnomusicology and I believe had written one of the texts for that. His take was perhaps less musical and more anthropological. That was rather different from how I had thought to approach ethnomusicology, which I imagined in part meant listening to a lot of music and understanding polyrhythms or understanding altered scales. All that's part of it, but that piece that was central in his approach was the role of music in 00:13:00culture, whether that's music accompanying funerals or births, whether that's music accompanying celebrations, whether that's music that people are simply whistling while they're performing work in the fields or while they're painting walls, or how it is they hum along with something, but humming perfectly. How music functions in people's lives, and that part absolutely grabbed me because I realized it's inextricable, the way we listen to things and what we regard as what is music versus what is not. That varies from one place to another. And what can be created afresh versus what has to be done absolutely perfectly each time; you have all different manner of interpretations of that around the world and I find that to be just rather extraordinary. The other piece of it is, for me, music takes you out of a purely intellectual cognitive process and lets you 00:14:00live in other parts of your--looks at other abilities and brings those together. So there is a kind of inclusivity there where passion meets creativity meets dexterity meets creativity. Again, music--because it's been part of my life for such a long time, it is very much the way I project myself into the world and certainly in the context of outbreaks.

Q: Was there an element of ethnomusicology that you focused on? I don't know if you had a senior thesis or something? Or it wouldn't have been senior, but--

MANNING: I was looking around and I never quite found what I wanted to do there. It could have been African music because that was something I thought was pretty compelling. It could have been Indian music because there is a kind of huge tradition there analogous to the Western classical music tradition with rules, 00:15:00regulations, forms and all that. The other was another possibility, was simply different traditions of musical instrument building. How people learn how you put together musical instruments, because many of them are simply not that easy to build. In order to do that, you have to have a level of expertise that takes you beyond even, like, fine cabinetry. That part was captivating to me as well, but I ended up not picking any of those. [laughter]

Q: What year did you graduate from grad school?

MANNING: I didn't finish my master's, and I didn't finish the PhD program. I sort of decided that wasn't really--I had gotten out of it everything I possibly could have and then I simply wanted to play music, so I did.

Q: So what happened then? What did you do?

MANNING: I was in bands for a while. The strange little pivot point, and I'm not 00:16:00sure how germane this is to your line of inquiry here, but the major deal was I had been working in Boston for a company that was making training products--video training products, print training products--for geologists and geophysicists and engineers, so I was already in the training groove. I drove home from work in Boston one day and on NPR [National Public Radio] they had this guy who in '95 was in Zaire on behalf of the World Health Organization responding to the Ebola outbreak that was unfolding there. It turns out that he was a former EIS [Epidemic Intelligence Service] officer from CDC named David [L.] Heymann. I didn't know who David Heymann was at the time, so I stopped the car to hear him report out of Kikwit I believe in Zaire. It was really a pivotal 00:17:00moment, and I remember it quite vividly, pulling over to the side of the road to hear what this guy had to say. It was very candid. It was a discussion of risks and prevention and health messages, and I thought, this is where I need to change direction and see if I can get a hold of this guy and try to reach him. [laughter] In those days, e-mail was just barely getting going, but WHO, the World Health Organization, oddly they listed their staff e-mail addresses on their web page, which was a god-awful web page. In '95 everything was a god-awful web page.

I wrote to this guy, David Heymann, and I said, "Here's what I do." And David Heymann said, "That's pretty cool, can you come over and talk to us?" I thought 00:18:00yeah, I'll go to Geneva and I'll talk to David at the World Health Organization; that could be fun. Well, David turns out to be the head of a newly formed department looking at remerging/re-emerging communicable diseases. I presented to twenty odd people, pretty much the senior infectious disease people at WHO. I had no knowledge of really quite what the environment was that I was stepping into, but I was very prepared and in '96, by the time I was presenting, I shipped over my big desktop computer and I played for them a video that I had made that was on the computer, and in '96 that was a big deal because it played at full resolution on a normal TV. When I hit the spacebar and the video played, everybody went, whoa. So David said, "Come on board. We want to work with you 00:19:00for various things." All that tech training with respect to geologists and engineers and geophysicists, it was simply a change of subject matter, but you're still organizing information and you're still using video to present it or you're making print products that organize that information for those who were going to be learning it. It felt pretty fundamentally right to move in that direction. I stayed at WHO working as a contractor for like eleven years or so; sometimes with David, sometimes with others as well, but learning the topography of international public health, whether it was for HIV, whether it was for immunization or whatever, and that all happened before I got here. Again, another opportunity or a set of opportunities to look at how people are understanding health and understanding prevention and understanding protecting 00:20:00themselves. Again, these things vary widely in terms of what people understand to be causative in terms of sickness. Just like musical variety, there are differences in how peoples elsewhere understand what is health and what is sickness and what causes health and what causes sickness. Again, I was right in my element thinking oh, lucky me. [laughter]

Q: I have a couple of follow up questions to that if it's okay. Do you remember what was in that video that you played?

MANNING: Yeah. The one I made for WHO?

Q: Yeah.

MANNING: I had gone online; again, be mindful this is like '95, so online is simply a place where texts files are listed with not particularly any great layout. David Heymann had given a speech at Yale [University], a talk at Yale, and I said, I can use this as the basis of my script. He was making the point, which has been around--it seems like now it's pretty much orthodoxy in public 00:21:00health thinking--that germs can cross borders quickly. No particular group is unable to be affected. I basically took David's talk, turned it into a shortened script, brought in some pictures, some graphs and charts and illustrations and some footage and said, "I think this is what the future looks like. I think we are talking about infectious diseases. We are talking about their movement around the world. We are talking about a plan for what we need to do as a responsible public health institution and basically we can picture what David had been saying in Yale by putting it with images and editing it and having music on at the front and the back. They totally got it and then I said, "Remember, this is what happens when your television meets your computer and your telephone. This is the new environment of information exchange," and it's 00:22:00not like I had any great sense of what the future would hold, I just knew on a technology level that I was using these things to create information and when I flew out to Geneva and I hit the spacebar and it all played and people got it I thought, "Okay. I think I've said something useful here and maybe they're going to want to work with me. Whoopie." So that turned out to be the case. The video was looking at this matter of the ease of communicability of diseases around the world and therefore, if you extrapolate that forward to 2016, then you're looking at Global Health Security [Agenda] type stuff. You're realizing that some of what Heymann and others were saying back then has been taken to heart and the systems have evolved such that--even at CDC we have country offices and certainly at WHO--we're trying to do an increasingly more proficient job of 00:23:00monitoring what's going on out there, so that we stay on top of it. It makes absolute perfect sense, but in '95 and '96 it was quite novel, it was quite novel.

Q: I appreciate that kind of parallel that you drew between the change in communicability of disease and the changing just communicability of information itself.

MANNING: Completely.

Q: That's cool.

MANNING: I like that too because I think in my role as a health communications person, having been doing this for a while now, you can absolutely see that it's been one set of parallel steps evolving on the comms side, communication side, and the tech side and then an understanding of the epidemiology of diseases and the ease with which they can move across borders, etcetera, etcetera. You're just taking what is in some ways fairly obvious and making a response to it with 00:24:00the best tools that you have. I can see the threads going all the way back to then and before moving forward into the present day in West Africa.

Q: Can you help me fill in just a piece that I think I don't understand quite yet? Like mid-seventies I think you finished grad school, and '96 it was to the WHO?


Q: What's happening in about that twenty-year period? You said you were playing in bands? You also said that you--

MANNING: Yeah, yeah yeah. Let's work it backwards from when I started at WHO, which was in '96. There were fourteen years of working at this tech company in the subject matter areas of geology, geophysics and engineering. That was for a petroleum training company. Again, a kind of international place, training in multiple languages across multiple cultures in topics that are very esoteric. 00:25:00You know, migration of fluid through porous media; this pretty screwball stuff. But again, the rigor of geology, of geophysics, of engineering, at the time it was very familiar territory to me. One of the stranger ironies of that as a background was several years ago--let me go back to the petroleum engineering days. There is an equation widely used--and I'm sorry to be off topic here--there is an equation which is used to explain how fluids move through porous media, which is to say how oil moves through a rock. How water moves through a rock. Bizarrely, several years later I saw mention of this equation in 00:26:00a model for understanding how influenza moves through a population. I had this moment of, are you kidding? [laughter] Someone dared? Someone was able to understand that you can mathematically represent, potentially, the movement of an infectious disease through a population using an equation which was originally devised to represent how it is fluid moves through a porous medium. It doesn't seem strange now except that only had you been in the petroleum engineering side of things and then moved to public health, would you have any idea how bizarre that was. It's just really strange. [laughter]

Q: Let's talk a little bit more in depth about Bundibugyo. How did you come to 00:27:00CDC in the first place, actually?

MANNING: Maybe around '05-'06, I could see at WHO, that the short-term contracts and the longer-term contracts were becoming fewer. They were really thinning out, whether through a retirement process or just through attrition or whatever. The money wasn't there and I was really struggling to figure out what my next move would be, and I looked to the CDC website, out to the website, and I saw that they were advertising. I did get a position with Creative Services in '07, but then bizarrely another position was offered from the Viral Special Pathogens Branch. I didn't know enough at the time, but I called somebody and he said, "You've been offered a position in the Viral Special Pathogens Branch? Dude, drop whatever else you've said yes to and go there!" It 00:28:00turned out to be pretty spectacular, fabulous advice.

The Bundibugyo experience was, as I said earlier, my first step into an outbreak, and of course quite the baptism by fire because it was an Ebola outbreak in this remote corner of Uganda. We in the Viral Special Pathogens Branch were not eager to sound the alarm until we had absolute laboratory confirmation that it was Ebola. Indeed it was, and there was a new strain that eventually came to be called the Ebola Bundibugyo strain. We set about doing what we had done in other Ebola outbreaks or Marburg outbreaks, and that is, alert everybody at CDC. There was not really an EOC [emergency operations 00:29:00center] that needed to be brought to bear because this was a small outbreak and seemed to be likely to remain one. But we of course reach out to our familiars in the world of international response to filoviruses--that would be the people at WHO, that would be the folks at MSF [Medecins Sans Frontieres]. We know they're heading up that way and we know that we have to coordinate with them. A team of us went there and then we did rotations. I think it was probably early December of '07 when I went there and stayed through the holiday and then came back sometime in January. By that time, it was nearing the end of that process. Ask me your question again because I think I might have veered off course.

Q: No, you really didn't. My question was very broadly, just tell me more in detail about Bundibugyo.

MANNING: The idea that was clear to me--being sort of tech nerdy--was: bring a 00:30:00video camera, bring microphones, bring a laptop, and make sure you can find a way to keep everything recharged because there was no power out there. There was only a generator until seven o'clock at night. We were staying in this grimy place and meeting the various people with whom we had to work. Very fortunately, it was clear from early on in my working relationship with my supervisor, Pierre Rollin, that he was very committed to the comms, the communications aspect. So I went asking for money to do radio spots because everyone was telling me, as they were in West Africa, people get their information from radio. You've got to cover radio. You can make posters and you can do interviews, but radio is going 00:31:00to be the way to get this going. So I was able to have some money to do these radio spots. We were able to give a small amount of money to the radio station who was going to run them for a period of twenty-one days, several times a day in multiple languages. We went to the homes of the people. We got the translations going and that process was pretty challenging because you're in the field with the battery running down on your laptop and we're recording in candlelight and there's no generator running and so you're needing to get this thing to the radio station the following morning. We were able to burn those radio spots onto CDs and take them to the radio station and put them in rotation.

Now when I went to the radio station, nobody would shake my hand because I was the guy from the Ebola team and I was from Bundibugyo. As far as they were concerned, that was more risk than they were wanting to experience. It was also 00:32:00a period of time when it was very easy to see how shocking it is at the community level to have international responders come in and do things like put people in body bags or do things like isolate folks in wards from which they might not exit. And for there to be relatively little going out in terms of the communication to the community of what's been taking place. It played out again in West Africa. You have people who are being discharged following their illness, they're convalescing. They're basically very weak and they have to integrate back into a community which might or might not be able to accept them, and that was clearly obvious in Bundibugyo and we tried to get out in front of that. The radio spots addressed stigmatization. It was also the case that in 00:33:00Bundibugyo the health workers themselves were becoming stigmatized because they were seen to be perhaps at risk of Ebola, perhaps at risk of themselves becoming infected and then infecting others. They were having a hard time. We had to get on their side and speak about not stigmatizing the survivors of course, but also not stigmatizing the health workers who are in there as we put it on the radio. They are as valuable as water. They are doing their best work to protect Ugandans and we really had to get out in front of that.

If you ask me if we had any success that I can demonstrate quantitatively, I don't think I can. We had to work in, I believe, three languages that were spoken there and I think in the end what I was hearing anecdotally is that 00:34:00people were saying, thank goodness for the radio messages, because at least it gave the appearance that people who had information were in charge and were providing accurate guidance in a context of there being very little reliable information. Of course, in that void, folks might just come up with whatever they like.

Q: Can you tell me more about how you decided what to put in the radio messages?

MANNING: In the early days, you're not so concerned about stigma of convalescent patients because there aren't any convalescent patients; either patients are dead or the treatment centers--they're sick, but the illness has not run its course. So in the early days you're talking about prevention and you're talking about transmission and you're talking about symptoms. That stuff is pretty well 00:35:00known. That stuff is pretty well established. You are indicating what it is they should do if they're getting sick. Those messages are fairly standard, and as you move deeper into an outbreak in the passing days and weeks you can begin more targeting of messages, which is what we saw in West Africa. I don't think we had the luxury of time--let me say it differently. I think we had to move very swiftly in Bundibugyo to recognize that we simply had to address as broad a number of people as we could, and were we culturally sensitive enough? I don't know whether we were because the effects of an outbreak of Ebola in the communities--it casts an enormously long shadow. Even in Bundibugyo, when I was asking around with some of the other clinicians who were African who had worked 00:36:00at other outbreaks of either Marburg or Ebola, they were telling me in the smaller communities it might take two years for their community to recover from the challenges that they had to face. In the context of folks coming in in big four-wheel drive vehicles, isolating and taking family members away and hospitalizing them and then leaving when the epi curve seems to be reporting no new cases. I admire the swiftness, which is absolutely essential. We could have had more of that in West Africa. At the same time, the cultural devastation that is caused by not only the outbreak, but by the uniqueness and oddness of people 00:37:00in PPE [personal protective equipment] setting up isolation tents. That, I think, is very indigestible for people who have no cultural referent for that and I can see why they would hesitate to accept information from a group that seems so threatening.

I think we tried to address that and honestly, when you can speak this information in the language through individuals that are known in the community--we worked with a reverend in the community of Bundibugyo, I believe Hennington Bakuma was his name, a well-known figure. Someone who is involved in the translation of the Bible project. Someone who seemed to have an absolutely sterling reputation, but also is a very worldly fellow and spoke the local 00:38:00language. I think we made good progress in choosing that fellow to be the voice for at least one of those languages. It does make a difference. It gets very hard to quantitate how many lives were saved by that, just as it would be in West Africa. But as we saw there and as we saw again in West Africa, speed is of the essence, but it also imperils the culture because it's just going to be so hard for people to contend with what has to be done in order to prevent further spread. I honestly don't know where the balance is to be struck there, where the fifty-yard line is, but that's a tough one.

Q: After Bundibugyo and leading up to the West African Ebola epidemic, what were 00:39:00some of the other big things that you were involved in?

MANNING: I don't know if there are any other big ones. There was an outbreak of Rift Valley Fever in Madagascar. There were a couple smaller outbreaks in Ebola.

Q: I should have said "important to you," maybe.

MANNING: Let me think about that actually. One way to respond to that is to say that it was clear to me that in the aftermath of the outbreak in Bundibugyo that you do have a golden, teachable moment where you want to tell people how to avoid this happening again. I ended up going back to Uganda a bunch of times actually to work at the district level in training programs for the district 00:40:00health educators in Uganda, the DHEs. That was a way to leverage the fact that people were more attentive. Now that this danger had passed and some degree of balance had been restored, people are going to be asking, how do we prevent this happening again? The interesting thing which came out of the Uganda experience--and I think it's very much to the credit of the Viral Special Pathogens Branch. Not me, but the people who do the serious thinking. You take the experience of four hundred people dying in some outbreak in Gulu in Uganda or a hundred-and-twenty-odd people dying of Ebola in Bundibugyo and you say, what do we do to make sure this doesn't happen? Because there are instances of 00:41:00smaller outbreaks or outbreaks about which we don't even know they ever happened, which burn themselves out. You look and you say oh, there's a bunch of things we can do. One of which is you can intensify the surveillance, so at the district hospitals or at the sub-district clinics, you can train the health workers there to understand when someone shows up with an unusual febrile illness, that you simply don't call it malaria. You ask a bit more about what's going on. And that you have in place a system whereby those people at those sub-district clinics, if they suspect something out of the ordinary, they have the gowns and the gloves and they can protect themselves when and if they draw blood.

So, lesson learned there, good surveillance and then good protection. Next, 00:42:00adequate transportation of the specimens, the blood, through safe means with cell phone numbers, toll free numbers all the way to an in-country lab which can do the diagnostics, rather than sending it to Atlanta and waiting for a week. You basically--again, this is a lesson about speed. Those samples move down from the district onward to the lab that CDC has there in collaboration with the Uganda Virus Research Institute, and where the samples can be turned around in twenty-four hours and the information shared out. The evidence is there that when you put systems in place that are designed to surveil, to detect, to test and to report, that you basically can stamp this stuff out fast. It's anybody's 00:43:00speculation, well, what might have been the outcome were this to have been in place for someplace like Sierra Leone, Liberia, Guinea? Completely different outcomes of course, but it's kind of Monday morning quarterbacking to speculate on that. Where we need to go it seems, and health communications is an integral part of this, is to make sure that these systems are explained to the health workers who are going to be using them and that everyone buys in and then you have the messages going out into the community that you are protected. We have learned the lessons. We aren't going to see Ebola around here anywhere near the magnitude that we saw it from 2014 through 2016. The world becomes a better place and people don't have to worry that this is going to be something that occurred in the past and will occur again and again and again in the future; it 00:44:00shouldn't have to.

Q: So how did you get involved in the West African epidemic?

MANNING: Oh God, it was so weird. This is a conversation about information flow, and it begins and ends--and I had seen this with Bundibugyo--that no one gets out of their chair in the Viral Special Pathogens Branch simply because someone is speculating in a country in Africa that these unexplained febrile illnesses are Ebola. That's not enough. That's just rumor. That's just hearsay. That's just speculation. Things do get moving when the samples are tested at the lab 00:45:00and they are confirmed positive, and then everybody stands up and says we've got to go check it out, and so you move quickly to get in-country. Our branch was aware of an unusual death from an unusual febrile illness in Guinea, up around Gueckedou, as early I believe as maybe December of 2013, so that's going back quite a ways. I think the confirmation that it was Ebola was maybe around March of 2014. Pierre Rollin and I were sitting in my office--well he actually came in my office and he said, "The sample is positive for Ebola." Now, of course, knowing what we know, you wouldn't be surprised. But when someone walks into 00:46:00your office in early 2014 and says the sample is positive for Ebola, your head explodes and you're asking ecology questions. Why haven't we seen it before? What made it pop out now? What animals are implicated? Is there [unclear] the bush meat? Is this a rural place? And we've got to go. And that's basically the long and the short. [laughs] Because the novelty of it appearing there is interesting on a number of levels epidemiologically, environmentally, ecologically, anything. We went over there, Pierre and I and some EIS folks, to Guinea to understand better what was taking place, and we were eager to 00:47:00understand where events needed to go. Again, because Pierre is so supportive of the comms [communications] function, I was on that team that went over and Pierre plugged in very quickly and made a friend in the US ambassador at the time. Was introduced to the President of Guinea at the time. A whole set of things at the highest levels, which I was able to watch as they were unfolding, but I also had access because of Pierre's graciousness to putting him on camera and for him to do presentations at the US Embassy, the French Embassy, the British Embassy, to do radio spots all in this early period late March, early April 2014.

The Embassy was extraordinarily supportive--the US Embassy--was extraordinarily supportive as well. We had an opportunity to be on radio for free, on multiple 00:48:00radio stations. We had an opportunity to give messages that were well-honed, rather familiar to a public that was increasingly concerned. This was before the EOC had been activated. This is at an early stage where a small number of people are going in country with considerable expertise because you've got Pierre, and trying to look forward and say, where is this going to go and what do we have to do and what is going to take and what role does CDC have in this? And then what role does communications and social mobilization have in this? To say nothing of media relations and public affairs. So we have an emerging story, which is certainly compelling. We also have a potential Public Health Event [Emergency] of International Concern basically that we didn't see it yet, but we knew where 00:49:00this train might roll if indeed things were not going to be contained as quickly as they should have, and that was basically what happened. As much as we had learned in Uganda and DRC [Democratic Republic of the Congo], we didn't get it wrong in West Africa, we simply were faced with a much more overwhelming situation, and I think it was beyond the capacity of a [CDC] branch to respond to what was unfolding. Tough times at that point, but also a real privileged place for me in the sense that I'm sitting and I'm watching things unfold from the same vantage point that Pierre is watching things unfold. I have less expertise by far, but the inventing of a response is what you see and that's 00:50:00kind of amazing. It's based upon an assessment of the facts, it's based upon some judgment about what's going to happen next. It's not an improvised, ad hoc response in the sense of there being a lot of disconnectedness. It's very clear and concise, but it's a very different kind of development in the realm of human behavior. We're going to install something which is going to be big and different and challenging and we're coming [laughs]. And it's different.

Q: So it sounds like you have both tried and true messages that you have and Pierre has used in places like Bundibugyo, but then as you're saying there's 00:51:00also a need to listen to the specific circumstances, right?


Q: And to tailor your messages based on what you're hearing.

MANNING: Absolutely.

Q: Can you talk about that? What that was like in West Africa? What you were hearing and from whom?

MANNING: Yeah. This takes us into what I think is--from where I sit at least--one of the most interesting lessons learned from the West Africa response, and that has to do with the intense involvement of the behavioral sciences in the context of these kind of emergencies like in the Ebola outbreak. One of the things that made my antennae start to twitch early on was I heard that people were disinclined to believe that it was Ebola, that they were 00:52:00observing cases of Ebola. And what they were saying was, we've been told that Ebola, according to the health people who are coming to talk to us, the symptoms invariably include hemorrhagic symptoms, and we are seeing nothing up where we are that includes obvious hemorrhage. And indeed, hemorrhage was not as conspicuous a symptom in the West Africa outbreak as it had been in other places for a number of reasons. So already we are seeing a kind of dissonance, and people are saying we were told one thing, we are not seeing that, we are pushing back and saying it isn't what you are claiming. And there's a history of mistrust, and the civil wars and all that make people a bit disinclined to just 00:53:00accept whatever it is being told to them. And from that point forward in my thinking, I was aware that we have a communications challenge that is simply bigger than talking about prevention, talking about symptoms, talking about treatments, etcetera. We have a trust issue with respect to how information that is critical is going to be seen when there's already plenty of indication that that information is--where it has needed to be factual, it was inaccurate.

So as the response matured and as we in the health promotion team were able to recruit more behavioral scientists into that team, we were able to look--and as 00:54:00more people were being deployed as part of the health promotion team, like the numbers of people going in country are increasing and so, too, are the number of behavioral scientists. Then you can understand, then you can plan on the community level rather than the national level to design interventions, to design questionnaires, to set up focus groups whereby you can learn on a day-to-day basis what's changing, what's evolving, where there was resistance, where there were pockets of non-understanding, what are these people objecting to and what are these people thinking. And you could have that early on as we--there was a woman we were working with not closely but she was part of UNMEER [United Nations Mission for Ebola Emergency Response], she was an anthropologist and she was what has come to be called an applied anthropologist. 00:55:00This means someone who can go in, do an assessment and report out the same day and recommend the intervention, an intervention that would explain why people are behaving in the way that they are, working on the assumption that people do behave rationally and trying to explain to us on the other side of that fence what it is we don't know so that we can do a better job of messaging on this. And that became a lynchpin of how the health promotion team worked, certainly in Sierra Leone, not to the same degree necessarily in Liberia or in Guinea.

That level of expertise, it seemed to me, we became--the notion came to in Sierra Leone to create something called the Social Mobilization Action Consortium, or committee, I forget which. And because it was a healthy number of 00:56:00people from CDC in Sierra Leone doing health promotion at that time, they could reach out to the business community, they could reach out to religious groups, they could reach out to the local media and they were able to pull in and create a campaign which became--you've heard this already--the Ebola Big Idea of the Week. That's not a small accomplishment. That it was driven in good measure by the behavioral science perspective, and enabled me to see for the first time that the behavioral scientists are guiding us to better understand what are the real events going on in the ground, and beyond that to see the value of--to see 00:57:00the feasibility to bring together all of these partners. Could you do that with two or three CDC people in country on the health promotion team? I didn't see it happening. But when you have that large a number, and you can move into the communities as well, you can do a heck of a lot with that level of expertise. I mean CDC was pretty awesome in terms of the prowess and the skill sets. I mean, exceeding that of UNICEF [United Nations Children's Emergency Fund] in number, and for the most part in terms of skills. Certainly MSF has those skills as well, but not the numbers, and WHO had probably the skills but not the numbers and they were focused more on media than they were on the kind of social engagement piece of this. So I think we rather nailed it. On the other hand, this was a remarkably difficult response, but the lessons for me out of this 00:58:00were that when you have a certain critical mass of individuals with the right set of skills organizing out into the community, you can achieve an enormous, enormous amount. I don't think you can do that with one or two people coming in and doing health promotion with having to report back to Atlanta every twenty minutes. But in that context, when you have enough people and they're the right people--and there's some notably amazing people who were there--then you can achieve great results. And that was a very big lesson for me in terms of how things unfolded. I didn't invent that. That just arose organically, and it certainly convinced me once and for all and forever that the health promotion team, as we came to understand what we were supposed to do, it was a huge piece of the response. Huge. So whether others understood us, I'm not entirely sure. I think sometimes we were perhaps interpreted as public affairs and we weren't, 00:59:00but everyone tends to see the comms people as public affairs people but it's far beyond that.


Q: I think I want to pull us back into Guinea a little bit. While you were in Guinea, were you doing these questionnaires and focus groups or was that more of a Sierra Leone thing?

MANNING: That was much more--my time in Guinea was so early days and so predicated upon Pierre's willingness to make himself available, and in some ways I was more like Pierre's handler, and I happened to have a camera and the video editing gear and I could make PSAs [public service announcements] based upon what he said. The comms team from CDC working in Guinea at that point was one person. Well, two if you count Pierre, who does an awesome job of communicating. 01:00:00But between us we were able to, I think, leverage that extraordinary set of doors that opened at the radio stations, at the TV station, with support from the embassy, with support from the ambassador and with support actually from the highest levels of government in Guinea. So a very different operating environment because it's early days, the Ebola thing is notable and concerning and it's on top of mind for everybody, but the bodies in the street part that we saw in Liberia, that was not part of Guinea at the point when I was there.

Q: When I've spoken with Pierre, he has mentioned, especially in regards to 01:01:00Guinea--and you've touched on it, too, a little bit--just a history of distrust between the center and the periphery, the government and especially in Guinea the Forest Region, and he talked about witnessing some--what am I trying to say--

MANNING: Evidence of this mistrust.

Q: Evidence of the mistrust and evidence kind of a demeaning attitude held by people from say Conakry when talking about people from the Forest Region, as part of a pattern that he's seen elsewhere in other responses as well. Did you encounter that?

MANNING: I think I see it differently. What I note when moving from the capital city to the countryside, is that you may have government that is national 01:02:00government and it has a president and it has a parliament and it has representatives and so forth, and they come to the capital city to meet and they enact legislation and they plan budgets. However, that sits atop, when you move out into the rural areas, the system of tribal governance. And this has its own infrastructure and it has its own rules and it's not inherently in conflict with national governance, it's just that national governance doesn't necessarily have the means to consistently deliver out to the people in the rural areas. There's evidence of this in rural America, so it's no surprise. And there's a bit of I 01:03:00suppose suspicion in the rural areas as to whether the people who come to visit them from the city and make claims, whether those claims will ever be backed up by action and so forth. So that has a piece of it. And in the areas that are tribally administered through the tribal systems, it's not as though they claim any legitimacy, it's simply that they've been there longer, people understand them, the rules are in place and life has gone on that way whether there are skyscrapers going up in Conakry or not. So it's important that we, when we move into that, express an understanding, acquire as quickly as possible an understanding of this is what it looks like and it's more layered, it's more nuanced, it's more patchwork. There was an ethnic piece of this, there was a 01:04:00regional piece of this, and we as guests in that country are well treated and made welcome, it seems to me. That's been my experience and our ignorance of how all these systems work together, we're forgiven for our not understanding that terribly well because I don't think anybody else understands it there either terribly clearly. So we move in with what I think is our strongest hand, which is the expertise that we bring to bear in outbreaks. That's respected. That moves past the reticence, that moves past the uncertainty, that moves past the mistrust and as odd as we are, because we look different and we act different and we eat different foods and so forth, we are welcomed because we bring the expertise. And I think that's not a simplistic account, that's a genuine statement that our strength was recognized early and perpetually in the context 01:05:00of this response. So I think that's what we do exceedingly well and we've got to be mindful not to stumble and do something which is culturally inappropriate. But by and large I thought we sort of managed ourselves pretty well there. I'm not sure I can see it--I mean there is ethnic conflict. There is so much that we are not seeing as to why things are working in the way that they are. So I just have to kind of take one step back and say, from my anthropological training, and say I simply don't know and it's okay to ask a question and have someone explain to you why it is there is refusal to do this, why it is there is persistence in doing something else, and try to sort of move that along and 01:06:00offer some alternative to that.

Q: I understand. You want to center on the expertise that you do have. That makes sense. Were there ever times that you learned or got a sense a little bit of different tensions, be they regional or ethnic, and could incorporate them into messaging? Did that ever happen?

MANNING: I don't know if I'm going to find you an answer to that.

Q: That's okay.

MANNING: The place where I saw time being wasted in the early days was in context where you had to explain to country leadership, not necessarily at the 01:07:00highest level but at the mid-level, how an Ebola outbreak is extraordinarily urgent, far more so than cholera, far more so than most anything, far more so than an immunization campaign. And I had the sense, and I don't say this disparagingly, that people who are more familiar with long term public health engagements have a hard time wrapping their heads around acute responses to outbreaks of infectious disease. And even if that's not an acceptable characterization, I would then say, well, people had a hard time wrapping their 01:08:00heads around the urgency of an Ebola response. That is a paradigm shift and it took me some time to make it, it took some of us here at CDC some time to make it, and we can't be castigating our colleagues anywhere else for their needing some time to process that. I don't know how you accelerate the understanding that this is a paradigm shift and to compel people to--not compel but to share your own recognition that this is a seven-day-a-week event, that you don't just stop working on Friday and come back on Monday. There will be some people who don't want to accept that, but they eventually end up accepting it and then they get onboard and work as hard as they possibly can. Other folks are simply 01:09:00saying, no, it's more than I can handle; I have family, I have other obligations, I have things I need to do. And you try to move people who are willing to accept that this is sort of a different way of operating and if you succeed, that's wonderful; then you're building strong partnerships with people who are totally your comrades-at-arms moving forward. But if there aren't folks who are getting it for whatever reason, no blame, no nothing, just you just keep going. You just keep going.

That's why it gets exhausting, because in the response you have people who want to come on and serve from CDC and you tell them accurately and honestly, you're going to work your butt off, and you have an odd and different risk and that is if you do this for thirty consecutive days and nights and don't have any time to 01:10:00take care of yourself, you will burn out and you will be exhausted and you will be needing to take a rest. And because we're such overachievers here, there are people who just exhausted themselves and it's not fair to them, and they accomplished extraordinary things, but they were at the other end of the spectrum which is they're going to run till they drop. They have no trouble understanding the paradigm. They have trouble just switching it off. [laughter] So I'm probably more one of them.

Q: So how did you feel coming away from that first early deployment in Guinea?

MANNING: I didn't have the sense that it was going to become a major public 01:11:00health emergency until I started seeing the numbers come back up. That told me that despite the condition of the roads, people are traveling. This told me despite the fact that it's rainy season, people are traveling. That realization stood on its head everything I was thinking about where we need to go next because it was portending--because within that fact embryonically is the next six months to a year of what we need to be thinking about doing, starting with the observation that this is spreading fast and broadly. We have to wrap our 01:12:00heads around the idea that we are seeing the emergence of a phenomenon that we have not seen and which is not necessarily very analogous to what we had been seeing in Uganda or DRC. And what will we as a [CDC] branch, what will we as an agency need to do to put up something that responds to this phenomenon which is moving and changing shape, and yet we've got to say at certain moments we will do this and then we will do more of this and then we will add some of this and then we'll do some more of that.

I was aware as we moved into the autumn of 2014 that the health promotion team, 01:13:00which had as one of its notions to send maybe three people into country, that that whole idea was just ridiculous. We needed to find more people sooner and put them through a training process and monitor them when they were there, make sure they felt supported, build products for them, help with translation. So you have a team back in Atlanta which is not one guy with a cell phone named Craig, but a bunch of people around a table who are setting up meetings, engaging with the other teams, and we are building this thing as it turns out that we called "health promotion" and it became another box on our chart just like epi [epidemiology], just like diagnostics, just like logistics. It became clear that this juggernaut, this little team that we are trying to build and make larger for health promotion, is rather like what everyone else is doing which is: 01:14:00they're building their teams and being sure that they get larger as well. So you're in this--it's not a fog but it is a process which involves not only responding to what is happening as best you can with the resources you have in West Africa, but in your spare time standing up the next version of this, 2.0, which has more people, more resources, more challenges, more demand, asking people to stay longer, looking for certain skill sets that we didn't realize we needed before, and in the thick of that basically building something on the fly, which is remarkable, and to do this with people who have never done it before. I don't know how to convey successfully a sense of how daunting a task that is. 01:15:00I'm not whining about it; rather it's just momentously huge because you have to have a sense of so many moving parts, what's changing, where the opportunities are, how to take advantage of them, and how to make sure if you are doing that, that you have some results that are being achieved and you can say, yes, we're doing a good job of that; or we're not doing a good job of that, then we better go fix it. And that part was pretty--if you want to just be--it's like crossing a deep, fast river where anything at any moment can just rewrite your plan and 01:16:00there's no opportunity to fail. You just have to get across the river. That's it. That's it. And there's nothing short of doing that that is going to work, period. So you have that kind of--the cliche about this is "failure is not an option," and I get that. It's a bunch of words that sound cool. But in the middle of it, it just scares you to death.

But that was how, as we moved with this form, called the "health promotion team"--I said at the beginning to people when we were first putting the box on the org [organizational] chart, and I might've said this to you before, that we are only going to ever be West Africa-facing and we are not a public affairs group. And those two things in my mind, based upon Bundibugyo, were two things 01:17:00that enabled us, I think, to keep our eyes focused on what we were able to do in-country on behalf of preventing transmission. And I had my own experiences with dealing with media celebrities like Sanjay Gupta who came into town in Guinea, and no diss on Sanjay, but the guy takes up a lot of time. In the fast-moving context of an Ebola outbreak, a day of Sanjay for me is like--it's eight hours. It was actually about twelve hours of dealing with--again, I'm not besmirching Sanjay Gupta, but I could not take my eye off the ball and if we needed the media relations person to deal with that, that's fine, but it wasn't me and we had other fish to fry. Sanjay--I'm not excoriating Sanjay but it's 01:18:00just there were more important things that absolutely needed to be done and I'm sure he's aware, but it didn't make his job any easier to have to deal with the likes of me. [laughter]

Q: Well, maybe that's a good point to stop then. It's about 2:30.

MANNING: After I've castigated Sanjay.

Q: You really didn't. [laughter] No, it made sense, and actually people have said similar things about CDC leadership itself, that when CDC leadership comes, then that takes up a bunch of your time.

MANNING: It does.

Q: That makes you take your eye off the ball and, of course, CDC leadership themselves know that because they've been in the trenches themselves at various points.

MANNING: Yeah. That was less horrible and it was because the kind of information that Frieden was asking, he asks damn good questions and you don't always know where he's coming from. You know where he's coming from, you just don't always 01:19:00know what he's going to ask and so you prepare extraordinarily. But on the other hand he comes away with what I could see over time was a very deep and broad understanding--and I think he could interpret the information and turn that into action steps, and that's hugely to his credit. I'm not trying to praise Frieden because I barely know the guy, but in terms of someone who parses information extraordinarily capably, he's pretty damn good and that's kind of an amazing guy. I mean you can delete that. I'm not saying that for his benefit, I just think--

Q: No, I've heard the same thing from many people. He has this natural ability to process things and define the main points of things and, as you said, turn 01:20:00them into action. So it's cool to have a political appointee who can actually do all that stuff. [laughter]

MANNING: I mean the guy is pretty talented. I've been on the wrong side of him only once, so I don't want to have that happen again, but he asks good questions and he turns them into action. I mean for all the complaining, I'm sure that you'll be hearing about how this response was managed--

Q: Yeah, I've heard some.

MANNING: I think he showed good instincts.

Q: Okay. I can't thank you enough for being here.

MANNING: Thank you for having this open-ended--I think this is a bit more pleasant to go through as long as I'm not boring you to tears.

Q: Not at all. Pretty fascinated over here.


MANNING: So I think you've chosen a good way to go about it. It feels very organic and that's kind of cool.