Daniel Martin

Daniel W. Martin

Q: This is Sam Robson here with Dan Martin. Today's date is November 18th, 2016, and we're here in the audio recording studio at CDC's [Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Dan as part of the CDC Ebola Response Oral History Project. Dan, thank you so much first of all for being here. For the record, would you mind stating your full name and your current position with CDC?

MARTIN: I'm Daniel William Martin. I am a public health advisor with CDC and have been for a total of about fourteen years. I am presently working in the Epidemiology, Informatics, Surveillance, and Laboratory Services branch of the Division of Global Health Protection at the Center for Global Health.

Q: If you were to give a capsule description of your work on the Ebola response, just a few sentences long, what might you say?

MARTIN: The majority of my actual response work was as a field epidemiologist and CDC team lead in three different districts at three different times in rural 00:01:00Sierra Leone. That was my role, was a combination of the actual disease tracing and control epidemiology and leading the other epidemiologists, health educators, infection control specialists and so on that we had in a single district team. That varied from one time to another, so as we get into the particulars I'll go into more detail on that.

Q: That sounds perfect. And you also went on to have a longer-term commitment to the region?

MARTIN: Right. After two responses I was identified by the country office as someone who had been somewhat helpful in the process and they actually pulled me from my--pulled me, it sounds like it was involuntary. I wanted to do this. I was laterally transferred from my previous job in National Center for Immunization and Respiratory Diseases, the Immunization Information [Systems] Support Branch, which was a totally domestic public health role. I lateraled 00:02:00from that into what was at the time called the International Task Force for Ebola in the activated Emergency Operations Center. As the EOC spun down, the ITF, the International Task Force, became the Ebola Affected Countries Office within the Division of Global Health Protection, and our role there was to continue to support the three Ebola-affected countries, Sierra Leone in my case, in basically buttoning up the end of the outbreak and transitioning to recovery, post-outbreak recovery of the public health system. From that point on, I was supporting the country office in Sierra Leone, traveling a fair amount--I've been in Sierra Leone five times this year. And doing what I can both on this and that side of the Atlantic just to help the country office get its health systems restoration, its Global Health Security activities going.

Q: Perfect start. We're going to jump back in time now if that is cool. Would you mind telling me when and where you were born?

MARTIN: I was born in Iowa City, Iowa, December 11th, 1962, so I'm almost fifty-four. My dad was teaching at a small Mennonite high school in Iowa at the time I was born. I don't remember being there. I was only a year and a half old when we left. During my whole childhood, due to dad's teaching and going to grad [graduate] school and so on, we never lived longer than six years any place, but most of my growing up years were actually in California. Dad went to grad school in San Diego and then we lived in Upland, east of Los Angeles, through my eighth grade years. Moved to Pennsylvania, which is my dad's ancestral home, during the time I was in high school. I was a bit of a nomad growing up.

Q: What again was your dad teaching?

MARTIN: High school math and college astronomy, depending on the time. Different shots, different times.

Q: Went to get the degree in astronomy?

MARTIN: Got the degree in astronomy at San Diego State [University] in '68 to '71. That was my kindergarten and elementary school years.

Q: Did your mom also live with you?

MARTIN: Yes. They still are together. My mom was a stay-at-home mom our whole life. She has had a few jobs once we were out of the house, but she actually trained as a linguist. Before she met my dad, she had actually hoped to become a translator with Wycliffe Bible Translators and has that background, but then when she and Dad got married things took a somewhat different turn. I was born just before their first anniversary, so she was a mom right straight through.

Q: So you were in California until about what age was it?

MARTIN: I was fourteen when we left.

Q: Can you describe your life in California a little bit?

MARTIN: What I remember the most, obviously, when we were real little, San Diego was go to the beach for dinners. San Diego was kind of a sleepy town in those days. Dad was in grad school, so we were living on a shoe string. There was not much in the way of budget for entertainment that would cost money. But throw a picnic in the basket and go down and build a fire at Ocean Beach in San Diego and roast hot dogs and watch the sunset, that doesn't take much money. That was the years when Dad was doing his graduate degree. I remember going to the college's observatories sometimes, because of course, astronomy is nighttime work. We would spread our sleeping bags on the floor and we would go to sleep while he was doing photometry and spectroscopy for the work he was studying for 00:06:00his master's [degree]. When we moved to Upland, he was teaching at a junior college in Whittier. Started their astronomy program there. In fact, they installed their brand new telescope in the observatory I believe one of the first weeks we were there, and the most memorable part of that was that dad instigated, as he has everywhere he's had an observatory, weekly or semi-weekly public nights where the public was invited to come see the stars through the telescope. As I got older, and by older I really mean like only ten, eleven, twelve years old, the main telescope that was in the observatory with the dome like you're used to seeing, Dad would usually be running that, but there were a number of smaller telescopes that we would roll out on the concrete apron around the observatory and Dad had us boys helping people see other neat objects in the 00:07:00sky through those other telescopes. I remember many times going down, the whole family would go down for the public night and have a night of stargazing with whoever showed up.

Q: What were your early interests in school?

MARTIN: I don't remember exact--well, I've always enjoyed science. Growing up in the home of a science teacher, surprise, surprise. Somewhere in my probably junior high years, and I don't remember exactly when it was, I started feeling pretty strongly that I wanted to be a missionary doctor when I grew up. I grew up in a--not exactly conservative the way people usually divide the terms, but certainly a very orthodox Christian, sometimes Mennonite, sometimes Church of the Brethren, depending where we lived, household where the nonviolence of the Mennonite and Brethren traditions was very important and this was during the Vietnam War, so that was a thing. I had two uncles that were working in Vietnam 00:08:00with the church. There was this sort of idealism, I call it I was raised a terminal do-gooderism. There was this idealism that somehow, if you're really going to make your life count, it's going to be some kind of service to the poor and disadvantaged, preferably though, not necessarily with a religious underpinning, but actually that's one of the ways my parents weren't classic conservative. The service was more important than necessarily having evangelism component with it. I've dealt with that all my life. When I've had jobs that are more, shall I say, circle-of-life, maintenance-of-things kind of stuff, I've never been as satisfied because there is an element of me, despite my best efforts to respect just the honor of hard work, which I do, there's an element 00:09:00of me that is not satisfied unless I am somehow doing something with a higher calling. It has at times made me a bit insufferable I think, but it definitely is one of those things that I think mostly positively, and occasionally negatively--it's been a real strong driver in my life.

Q: So you go age fourteen to Pennsylvania. What were those years like?

MARTIN: Going from the cosmopolitan Southern California, Los Angeles area to the very conservative Mennonite Lancaster County, where I had neighbors that had literally never been outside their county, was culture shock in the extreme. I find even as an adult that the Mid-Atlantic Pennsylvania, Maryland, Delaware kind of culture feels kind of stifling to me. It's an area where my observation is that even the non-conformists conform. They rebel in such predictable ways, 00:10:00they merely choose a different paradigm to which to conform. When even the rebels are predictable, I find that a fairly boring life. [laughs] So it's not an area I have any particular desire to remain tied to. On the other hand, it was a time where I got a chance to live in a rural area. My mechanical and fix-it--neighbors are farmers, you're always rigging something, making something work that's broken. A lot of my fearlessness around machinery and electrical stuff and just generally systems definitely was strengthened in that. Like anything, it had its ups and its downs. It was a good time.

Q: Did you continue wanting to be a missionary doctor through high school?

MARTIN: I did. In fact right through into college. It was interesting. I went to Goshen College, which is a Mennonite school in Northern Indiana, pre-med. I loved my biology and physics classes in high school. I went into college, and like many fairly successful high school students, discovered that them as cruises in high school doesn't necessarily cruise in college. I ran smack dab into having to actually work for my grades [laughs] and it hit me pretty hard. I finally got to a rhythm on that, so I was able to do okay, but by the end of my sophomore into the beginning of my junior year, it was becoming rather obvious that I was not doing well enough in my required pre-med courses and quite frankly, I was enjoying the rest of my college education and kind of hating the--especially organic chemistry, which killed me. Really not enjoying or 00:12:00desiring to work hard in those areas that I had to succeed in if I was ever going to be a doctor. That resulted in somewhat of a crisis of direction that I took a somewhat odd response to, and the winter of my junior year--in fact while I was home on Christmas break, I talked to the mission agencies of the Mennonite church of which I was still a part at the time and said basically, I'm looking at possibly volunteering some time and taking a break from college, here's my skills. I was by that point fluent in Spanish, and again I said water, maintenance, hardware, mechanical, electrical stuff like that I was very skilled at. So basically, these are skills, can you use me? The Eastern Mennonite Board 00:13:00of Missions said yeah, actually we need somebody exactly like you in Tanzania.

I'd never considered going to Africa. In fact, it was weird because when I would talk to my friends about wanting to be a missionary doctor, we're talking late seventies now, everybody would always assume that means going off to the wilds of Africa because that was the stereotype in people's minds. Perhaps just in response to the stereotype, I said well no, not Africa. I speak Spanish. I like South America. I wasn't prepared for their answer, but I took them up on the challenge and instead of returning for my senior year to college, I went to Tanzania where I worked in the Shirati Hospital, which is a mission hospital on Lake Victoria right near the Tanzania-Kenya border, for two years. I became fluent in Swahili, worked mostly with a large, multi-village water project, and 00:14:00also just hospital maintenance, diesel mechanics--keep the generators going, keep the cars going, fix whatever needed to be fixed, often on chewing gum and spit because the materials are hard to come by when you're in rural Tanzania. In those days--and this will be an interesting sidelight for later--in those days, communication with the outside world was either ham radio if the atmospheric conditions were just right, which they often aren't, but long about ten, ten thirty at night we could usually get a window where on fifteen or twenty meters we could talk to the US, once in a while. The other communication was a mailbag that we had to drive seventy miles to the town of Musoma to get, so we got a mailbag maybe once a month. That was it. That was our link to folks back home. 00:15:00As an aside to that, it's really wild that ten years later I was working for CDC in Zambia and I was able to use a direct dial modem and send e-mail. Ten years after that, I visited Democratic Republic of Congo with a trip with one of my church groups and was able to pull a cell phone out of my pocket and direct dial my family for twenty-five cents a minute and use a BGAN modem, the Broadband Global Area Network modem pointed at the sky to actually remote control computer systems from ten thousand miles away. And of course now I go to Africa and I've got a BlackBerry on my belt and I'm getting my e-mail and sending pictures right on my belt. My personal experience of the evolution of communication in Africa is kind of crazy.

Back to the story at hand though. The two years in Tanzania helped me to 00:16:00understand that my interest was actually in population health and preventive care and not in curative medicine. I watched some of my dear friends who were doctors in the hospital, who wanted to do public health and preventive work, but kept being pulled away by the urgency of the person who needed the surgery right now. I realized that at least in that setting--now obviously this is a twenty-one-year-old kid. My perspective has grown a little since then, but at least in that setting, the clinical skill was actually a liability to those who wanted to do the more population-based health. So with that, I came home, finished my bachelor's at Goshen in '87 and went to Loma Linda University in California to do a master's in international health. So that was where the shift from the desire for medicine, desire for public health and international health 00:17:00took place.

Q: I think maybe I'm missing a piece of it. You're in Tanzania. I guess you've always been interested in health in some aspect because you wanted to be a missionary doctor. The transition to preventative, to looking at the population also, was there something that you saw? Was it working on water systems in Tanzania perhaps that made that jump for you?

MARTIN: No, I think it was actually mostly seeing people near death in the hospital who if they'd only been gotten to earlier would have been not even at risk. Seeing the desperation with which the docs [doctors] are trying to claw these people back from the edge of death at the end, when it would have been so much simpler to do an earlier intervention. Obviously, my perspective has grown more since then, but I think that was where the computation began to change. 00:18:00There's a story that I learned during my time in Loma Linda that illustrates the paradigm shift, although I didn't know it at the time when this shifted in my own mind. It's a wonderful story that I believe comes from somewhere in Africa, but I'm not sure, of a village that lives along the side of a river and they have a very peaceful existence. One day a dead body of a person, a dead person comes floating down the river and a member of the village fishes it out and then they have this council of the people in the village, saying well, what should we do with this person? We don't know where they came from, what happened, we know nothing. They determined that the appropriate thing to do is to mourn them as one of their own and bury them in the village. So they give the person the best honors they can and they bury them in the village. A few days later, two more bodies come and they do the same thing. This starts to become a bit of a 00:19:00pattern. Some weeks later, they actually fish a couple people out who are still living and they are able gradually to nurse them back to health and these people become valued members of the village. To compress the story. which can be told in a much longer form, the village eventually is all about fishing the bodies out of the river and burying them and fishing the living out of the river and caring for them. It becomes almost an industry in the village. It's a large part of how their life is evolving until one day a small child suggests, "Why don't we send somebody upstream to find out who's throwing these people in?" That question is the difference to me between public health and curative medicine.

Q: How was school?

MARTIN: Once I knew what I wanted to do, I always thought I was very comfortable 00:20:00in it. I certainly enjoyed my time there. I was really there to get the letters behind my name for what I already knew. I look back, it's pretty darn arrogant, but at the time, I figured I'd already been overseas. I saw how this stuff worked. Yes, there was some tools I could use. Epidemiology statistics, very useful, glad to have them. But I did feel like I was kind of checking the box to get the official credibility for what I already knew. Obviously in retrospect I learned a whole lot that was helpful, but that was my attitude at the time. It was also where I met my wife though. She came the second year, which is the next major transition in my life because as I was coming into my second year of the master's at Loma Linda, my faculty advisor had hooked me up with some folks at 00:21:00Food for the Hungry, which is I believe a Christian but non-denominational, I'm not sure actually, NGO [non-governmental organization] that's based in Arizona. Food for the Hungry was at the time recruiting for a team. There was a very nasty civil war going on in Mozambique. The way I understood that what happened is the road from Maputo to South Africa, Maputo being the capital of Mozambique. The road from Maputo to South Africa really was the country's lifeline and so although the rebels held a lot of the southern part of Mozambique, the Mozambiquan military exerted considerable effort to hold the road because they needed it as a vital supply line. A lot of refugees from the rebel-held areas actually flocked to this corridor because relative to what they were dealing 00:22:00with around, it was more secure for their day-to-day life than being out where the rebels held sway. Food for the Hungry was pulling together--these people had been in these camps for so long, they were becoming almost semi-permanent structures. So Food for the Hungry was pulling together a team of an agronomist, a water and sanitation person and a health person to provide some development assistance for the camps. They were specifically looking for single, unattached guys because it was a rough place. I was in fairly late-stage negotiations with Food for the Hungry to be on that team when it dawned on the girl who is now my wife and me one day that we were more than just friends, and it very shortly after that dawned on me that developing a romance is really tough to do when 00:23:00you're halfway around the world in a war zone. [laughter] It may take a little while for me to get clues, but I do occasionally discover something. As we were looking seriously at planning to get married, I suddenly was looking seriously at finding employment that would keep me in the US while she finished her degree.

As I was casting about for that, one of the--actually I think my folks were talking to her at the time, but our family had done a lot of work with Habitat for Humanity. We had done a Carter Work Project and had actually become friends with some of the Carter family. Billy [William A.] Carter [III], Jimmy's [James E. Carter Jr.] brother, who was kind of the thorn in his side during the presidency. Billy's wife Sybil [Spires] and his daughter Marle and I were 00:24:00assigned to the same house and became fast friends. Marle's got my same birthday as it turned out. When she heard that I was looking for work in the states, Sybil suggested, well, give me your resume, I'll pass it on to Jimmy, see if there is anything in the Carter Center. She didn't have to suggest that twice because of course the Carter Center would be an ideal place for somebody in public health to work. Jimmy passed my resume to Bill [William C.] Watson [Jr.], who was then working for him, former CDC deputy director, founder of the Watsonian Society, exemplar of all of us public health advisors. I met with Bill at the Carter Center and he referred me to the late Andy Agle who was at the time working in the International Health Program Office at CDC. Andy hooked me 00:25:00up with the public health associate recruiting team here at CDC. So through that strange linking of people, I wound up getting a job as a public health associate in 1989 doing syphilis investigation on the streets of Los Angeles. Interesting thing for a nice, conservatively-raised religious boy to start doing. [laughter] Boy did I learn things. I did syphilis control as a CDC public health advisor in LA [Los Angeles] for about a year and a half, '89 to '91. Worked with some people who are still here: Kristin [M.] Brusuelas who is in--I think she's in [OADP, Office of the Associate Director for Policy] now, Anne-Renee Heningburg, who's in global polio, was our field services director. Friends from the 00:26:00beginning are still there. Susan [A.] Dwyer, who's in the quarantine out in San Francisco, was my first supervisor. Great people.

Q: What was your day-to-day like in that job?

MARTIN: Oh, that was crazy. I would check into the office and find out what my assignments were for the day, but we would get referrals usually from people who turned up positive on either pre-marital blood screenings or tests in various clinics. If they turned up with a positive test for syphilis, we had to track them down, find out whether it was acute, a new infection, or whether it was just something from before. Particularly if there was evidence it was an acute infection, which you'd find due to symptomology, timing, etcetera etcetera, I would bring them into the clinic for treatment. I would interview them about their sexual practices and partners, identify contacts and then go try to find 00:27:00those contacts and screen them. We were trained in phlebotomy. If I was having an interview with you in your home or in a trailer park or in the alley where I found you or under the cardboard box where you might be, I would offer you a blood test right there. I'd draw your blood and take it back to the clinic. I got very good at drawing blood on junkies whose veins were all shot to heck. Then we would also do interviews in the clinic of people who came in to be treated for STDs [sexually transmitted diseases]. Strange, strange world. But it provided one of the foundations for why twenty-five years later I was able to respond to Ebola. The field epidemiology, there's differences on the calendar depending on the disease and what it's incubation and exposure patterns are, but disease tracking epidemiology is a fairly basic thing. Little did I know in '89 00:28:00that one day I would be taking those skills to West Africa on one of the scariest diseases known to at least the common psyche.

Q: What was your wife going to school for?

MARTIN: She was also in the international health program. She had done a dual major in biology and sociology and she was looking for something which combined the two for more school and settled on public health. When she graduated she also began working for the health department as a contractor, not as a CDCer, but we both did VD [venereal disease] control for a couple of years.

Q: So where do you go from there?

MARTIN: I took a promotion into immunization, worked as a junior public health advisor with the LA County Immunization Program for about four and a half years. 00:29:00Then, because of my desire to do international, I took a promotion and came back to the mothership here at CDC and worked in a program in what was then called the Epidemiology Program Office, EPO, from '95 to '97 in a project called Data for Decision-Making where I had projects in Zambia, Bolivia and Russia--nice, logical regional connection there. Enjoyable in some ways, made some friends that I still have there as well, but in those days, the EPO was a rather dysfunctional office. It was kind of a toxic place to work. There were some people working there who frankly were more involved in clawing and backstabbing each other to get ahead than they were in doing the job and those of us who were 00:30:00just trying to get the job done kind of kept getting caught in the crossfire. After a couple of years in that highly toxic environment, I bailed. I didn't actually think I'd return to federal service. Went to a consulting gig with my brother in Virginia. I thought I saw a pot of gold at the end of the rainbow doing health technology consulting. Like many pots of gold at the end of rainbows, it evaporated in fairly short order. After about a year of that, I went back to California. My wife's family is from San Jose and her father owned a heavy equipment dealership, construction equipment. Had a computer system that was crashing and burning. Not Y2K [Year 2000] compliant. This was '97, '98. I'd been a geek for years. I was going to help him basically upgrade his computer 00:31:00systems. I figured it was a one or two-year project and then I'd get on about my life, and family considerations happened and I wound up being there twelve years. But public health continued to call my name. I probably applied over the years for thirty or more different federal positions. I had not burned my bridges, so I still had reinstatement rights. In 2010 I was accepted for a position with the Immunization Information Systems Support Branch of our NCIRD Immunization Services Division, which basically meant that it was a position helping the state health departments in some major urban areas, health departments, work with immunization registries to track through digital form immunization records and help to get them more consolidated. That was a job that 00:32:00was able to combine my geek skills and my public health skills because I spoke both languages fluently. [laughter] There I served for just over five years before the Ebola balloon went up.

Q: Now when you're talking about the family considerations that kept you in--was it California? For twelve years?

MARTIN: Yes.

Q: Did those involve kids?

MARTIN: They do. Our first was born while we were in California the first time and our second in Virginia, but when our third, our youngest son was born and had Down syndrome, the support of being around my wife's family was particularly vital during some of those early, rather difficult years. He's doing well. He's sixteen, he's in high school. He's got his issues, but we live a happy and not constrained life. This is not a woe-is-me story by any means. But the fact of 00:33:00needing to be around family during Gabe's younger years was pretty important. It took me a little while to realize that the siren song of public health was still very much in my ears and then as I said, I probably applied over the years for a good three dozen positions. Navigating USAJOBS[.gov] is not easy. It took a while before I managed to land a position back here.

Q: So again working on the immunization records in states?

MARTIN: Yes.

Q: Do you remember what you were doing kind of immediately before Ebola?

MARTIN: Oh yeah. I was supporting, depending on the time, anywhere from a dozen to sixteen different state health department programs. I would visit most of 00:34:00them between every year and every other year. I was probably doing state site visits six or seven times a year working with a large cooperative agreement that was part of the Affordable Care Act money, specifically for enhancing the capacity of the immunization information systems to interoperate with private medical record systems around a program that I just heard recently has just died, but the so-called Medicaid Meaningful Use program, which was a program whereby the federal government provided incentive money to physicians and hospitals to upgrade their electronic health record systems and use them in a meaningful way. One of the criteria for that being inter-operation with an immunization registry. I had sort of a combination of policy role around 00:35:00meaningful use. I interacted a lot with Centers for Medicare and Medicaid Services and some of the national people there, but a lot of it was around helping our state and local health departments do their half of the job for meaningful use.

In that role, I had actually--because my desire remained for global health, I had actually tried to do a couple of different details. I had been name requested a couple times by the global polio program, but my supervisor had denied my details. It's the old "no good deed goes unpunished." I was too indispensable in my program and [they] didn't want to let me go. When Ebola came around, well I had to think about that one for a while because obviously, I was influenced by the hype too. It sounds really scary. When I was thinking about 00:36:00whether I would volunteer for that or not, I had to wrestle in my own mind with, am I making a decision here to put my life on the line and leave my wife a widow and my kids fatherless? It sounds dramatic in retrospect, but those were the kinds of things I had to go through in my mind. Once I came to the point of thinking this was something that I needed to do, then I needed to approach my wife because we have the kind of relationship where that's not going to be a unilateral decision. She was understandably nervous, but she also understood why I might want to do something like that and ultimately she said yeah, if you want to do that I think you should.

So then I approached my supervisor about volunteering and by that point, Dr. Frieden had basically said to the entire agency, you do not deny details for 00:37:00Ebola, we need all hands on deck. My supervisor realized at that point that if he were to deny it, I would probably share that information and he would be overridden. I don't think that even then he willingly approved, but he approved my detail. So I put my name in the hat probably in about August of 2014. The EOC was a little disorganized in those days. They were just trying to get their act together, and that's not a criticism. They were really going crazy over there. I remember Steve [Stephen C.] Redd saying once that the [Office of] Public Health Preparedness and Response people had felt really impressed with themselves for 00:38:00having deployed fifteen people at once a year or two before. [laughs] The magnitude of Ebola took a while to sink in for everybody. I figure it's not a problem to say that since Steve said it open session. Anyway, my name went in the hat somewhere along about August I think. I'd have to go back and look at my e-mails. I didn't hear and didn't hear and I didn't hear, which is a bit of an anticlimax after having gone through all that personal wrestling myself. I was bellyaching about that to a friend one day who said, "Well you know what, a guy that I went to EIS [Epidemic Intelligence Service] with is in the EOC, let me introduce you and maybe rattle a little cage there." The friend was Loren [E.] Rodgers with whom I work in the Immunization Information Systems Branch. He put 00:39:00me in touch with Satish [K.] Pillai who was very much--you've probably talked to Satish. Satish grabbed my resume and pushed some kind of a button because next thing I knew I got a call, but it wasn't from him, it was from somebody else saying okay, what background do you have in Africa? Oh yeah, you've worked in Africa before. You have a government passport already? Oh, that's awesome. You've already got your yellow fever, cool. Oh man, we can get you out in a hurry. And in about two weeks I was on a plane. Once that kicked through it moved fast.

October 14th or 15th, somewhere in the early "teenths," I was on a plane through Brussels to Sierra Leone. I knew I had been approved for an Ebola deployment two weeks before I went. I knew it was going to be Sierra Leone a week before I 00:40:00went. I didn't know what I was going to be doing in Sierra Leone when I got on the plane. In fact, I didn't know what I was going to be doing when I got off the plane. [laughter] The flight got in on a Sunday night. At the security briefing on Monday morning, I got an e-mail saying, you're going to Tonkolili [District]. Meet John Redd at noon, they're driving to Bombali [District], you're going along with them. I met John Redd, who I know you've talked to John as well. He has since become one of my dearest friends on the planet. And off I went to Tonkolili.

Q: And still with--what kind of idea did you have of what you were going to be doing? You know where you're going.

MARTIN: I had been briefed. We did have a pre-deployment briefing on the natural history of Ebola. We were trained how to put on PPE [personal protective equipment] and doff it. We had bags of PPE that we carried in our little 00:41:00backpacks. I knew that it was about contact notification and tracing, active case finding. I didn't know what it was really going to look like when I got on the ground and frankly, you don't know that until you're on the ground because even if you have done it a thousand times, the circumstance in the individual location is going to be different. My experience so far with response is there is an element of you make it up as you go along, which simply is part of being on a response. No matter how hard you try to prepare, no matter many times you've done it before, no matter how many hand-off reports you get from somebody who was already there if they were, these are fluid situations and you're going to adapt to what you see, what comes your way, what lands in your lap and how it 00:42:00meshes with your own skill set. Two epidemiologists who are transferred into exact same circumstances are going to wind up doing different things because we do--there is a base. Contact tracing, contact identification, disease finding, observation of symptoms, educating the people. There's things that are always in the tool kit, but how you apply them is going to be different by person.

Q: What's the journey like to Tonkolili?

MARTIN: Not the same now as it was then. It is paved road all the way. In those days, there were police checkpoints probably every forty, fifty miles where you would be stopped and have your temperature checked. They were trying to prevent the spread of disease or the movement of disease around the country and one of the ways they did that was checkpoints where they would stop anybody who has a 00:43:00fever and sideline them for further evaluation.

Q: What did a checkpoint look like?

MARTIN: Have you been to the developing world at all?

Q: Yes.

MARTIN: It's probably familiar to you that as you're driving along a road, particularly as you're approaching a major town in many parts of developing world, there will be a roadblock. There will be people in uniform carrying automatic weapons in varying degrees of spit shine or not so, and they will stop and ask who's in the car, maybe ask for your papers. It was exactly like that, only with the additional step of a contactless infrared thermometer, where they would check the temperature of everybody in the vehicle. This did not happen when I first got there. In later times, they actually made you get out of the vehicle. They had a roadblock like probably a hundred meters back from the 00:44:00checkpoint. They would make everyone but the driver get out of the vehicle and walk along a pathway to the temperature check and hand washing stations, wash their hands, get their temperature checked and then get back in the vehicle and proceed. The rationale behind that was if you were trying to hide the disease but too weak to walk, it was going to show in you getting up to the spot. Now washing your hands was also often in chlorinated water. By the time I was there a month, my hands were cracking from all the chlorine. Of course then there were times where there wasn't much chlorine in the water. You would always smell your hands afterwards and figure out if the bucket even had any chlorine in it.

That process also slowed the trip. Today, the trip from Freetown, which is the capital of Sierra Leone, to Bombali where we were staying in the town of Makeni, is three-ish hours. In those days it took five. The roads weren't any worse, it 00:45:00was just checkpoints. And we had a pass that said, "These are Ebola health workers, laissez passer," and it still took longer. The ordinary citizen who was traveling, the checkpoint was actually closed after dark. They had to wait in much longer lines. With a pass we could kind of jump the line. They could wait many hours at an individual checkpoint. So we went up to Bombali. There wasn't a decent hotel in Tonkolili itself, so we stayed in neighboring Bombali in the town of Makeni with the CDC team who was in Bombali as well, which is why John Redd and I got the chance to get to know each other so well. We were team leads for adjacent districts. I would each day get up and take the half hour drive, 00:46:00again on a paved road from Makeni to Magburaka, spelled Mag-bur-aka, M-A-G-B-U-R-A-K-A but pronounced "Ma-bu-ruka." That's where the district health management team I worked with was based, which was in really the western edge of Tonkolili. At various times I would go out into the field and frequently abandon paved roads shortly after leaving Magburaka. Then the transit became a lot more difficult. In fact, all of my photos and videos are actually a part of CDC Museum archive already, I gave them to them. That was where you first heard me in fact was when I was showing Mary [Hilpertshauser] some of those. Some of my videos of driving have actually been used as B-roll in some of CDC's work. I've 00:47:00taken B-roll of everything from driving through the monsoon rains to the really hellaciously bumpy roads to everything else. Some crazy, crazy transit.

Q: I appreciate the documentary instinct.

MARTIN: Well I'm a photographer and a geek, so I had fun with that.

Q: Can you just tell me about your first day going to Magburaka?

MARTIN: The facility where we worked--again, because I had worked in rural Africa before, there wasn't any real Africa culture shock for me. West Africa is different from Eastern and Southern where I'd been, but frankly, the whole continent has some--there is some familiarity that comes with being in developing-world Africa that I had been back and forth enough that that was not a particular shock for me. You don't know when somebody is going to get sick at 00:48:00a moment. There's this sort of back-of-your-mind dread going on. You haven't even really given voice to it, whereof more later. You're in a situation--African cultures, at least every African culture I have been part of, people are very demonstrative in their communication with each other. A lot of handshaking, back slapping, hand holding. Touch is important even in our culture, as standoffish as we white Americans are. It is an indispensable part of your interactions in much of the rest of the world, certainly in Africa. So to be in a place where both by law and through everybody's fear, people are following it, you literally do not touch another person. That was surreal. It 00:49:00was probably more surreal for me because of my prior African experience than it might have been for someone who'd never been on the continent before. It just jangled. It was just wrong.

I met with the people at the District Health Management Team, the DHMT. I started learning my way around who was who. I met one of the guys that I met early on, his name was James and he was a very gregarious fella who came up and introduced himself to me. I said, "That's interesting, I have a brother James." He said, "Well great, now you have a Sierra Leone brother. Hey, do you have any other brothers? What are their names?" I said, "Well, I've got a David and a Timothy." "We don't have a Timothy, but we've got a David. Hey David, come here, meet your Sierra Leonean brother!" Brother David and Brother James became my buddies.

Q: Do you actually call them that?

MARTIN: Oh yeah. That was an ongoing source of interaction and connection for the rest of my month there. David is the more reticent of the two. It probably would not have stayed on with him, but James is one of these people that wears all his emotions on his sleeve, so there was no stopping that once it started.

Q: What did James and David do?

MARTIN: In normal times, James was the malaria focal point at the DHMT and David was evaluation and monitoring focal point. Both of them had shifted into Ebola-specific monitoring and reporting kinds of roles in the DHMT. David didn't get out in the field a whole lot, James did. In fact, he came with me to the 00:51:00field a number of times. I met other people who were there. Dr. Osaio Kamara, who was our district health manager, district health officer. A guy who I became dear friends with by the name of Augustine Kargbo, who was our contact tracing lead, who was a bit of a cowboy.

Q: What do you mean?

MARTIN: Augustine, well first of all, he does everything with the boundless energy of a spaniel. He's just bursting with energy and he's very friendly. Second of all, he took the idea of chasing down people who might be contacts or cases of Ebola with perhaps a little more glee than was appropriate. You got the impression whenever the new case came in and he would get ready to charge off to go find him, kind of an episode of Cops, "whatcha gonna do when we come for 00:52:00you." It could get to be a bit of a production with vehicles going charging out. Enthusiasm was not lacking, we'll put it that way. But the guy was such a sweet guy that you couldn't not like him. He was all kinds of fun and that actually is an interesting point about the whole time that I worked in Tonkolili. It was a dark time in that we were, I now know, in the actual peak of the epidemic. November 8th, 2014 was the day we had the most lab-diagnosed cases in Sierra Leone. One hundred eleven cases were diagnosed that day and that is the peak day of the epidemic. In Tonkolili, the peak was actually slightly later. It was slightly after I left, but it was still very much on the upswing when I was 00:53:00there. Tonk [Tonkolili] had actually gotten cases later than some of the other districts. Actually, I do feel pretty strongly that activities that we did helped to bend the curve and keep it from going higher there. I actually feel pretty confident that some of what we did directly limited the amount of Ebola in Tonk. In the midst of that very dark time, almost everybody you knew had either friends or family members or both who had either been sick and recovered or often had been sick and died. Yet, the day-to-day interaction was warm and cordial and joking and carrying on and enjoying each other. No touching, but a very warm camaraderie of interaction with the people. That combination was a 00:54:00very strange thing to be carrying in your mind. There was a real cognitive dissonance going on there.

Our normal days would start out with a report of the labs that had come in the night before. A determination of what we needed to do, where we needed to respond, focus our energies. When I first got there, there were two EIS officers also working with me. Well actually, there was another CDC epidemiologist that had been there for just a couple days, had started up the process, Mary [R.] Reichler. I don't know if you've spoken with Mary or not.

Q: I haven't.

MARTIN: Mary and I started while I was there, what in the long haul turned out to be one of the most useful tools we used in Tonk. We did not have enough data in the VHF, the viral hemorrhagic fever database, yet to be able to do much. They had a lot of case forms that had not yet been entered, so the digital data 00:55:00were not really useful yet. We took a very low tech approach--took a map of Tonkolili, a map that was actually provided by our GRASP [Geospatial Research, Analysis, and Services Program] team here at CDC and took a red pen and started spotting the cases. We went down through the notebook and we spotted the cases that we had already, and then each day when we got the new labs we would sit down with one of our DHMT advisors, a fellow by the name of Mohamed Okala Sankoh, who was intimately, intimately familiar with the geography in villages of Tonkolili. He would help us locate on the map the cases that had been diagnosed the day before, what villages they were from. We would--in fact I've got a picture of it I can show you, this is in the museum archive--we would spot 00:56:00those cases each day on the map and that would provide us--because we'd been doing it for several days now, right? It would provide us with a point of conversation because we would kind of see where the clusters were growing, right? We knew which of these clusters were things that we had seen in previous days and we saw where we were adding more red dots on the map and by doing so, just in our own minds with this visualization, we understand where we're seeing--here it is. This is a map of Tonkolili and as you can see, Magburaka is up here. This is this large red cluster here. It's no surprise you'd have a lot of cases around where the only hospital in the district is, right? But you'll notice that I've got several other major clusters of red dots here that are 00:57:00not--it's not uniformly spread across the district.

Q: Absolutely. They're in little clusters.

MARTIN: Right. This cluster for example in Mabamp had happened mostly before I got there. I visited that area. In fact, I'll show you a picture of it in a moment. But these two clusters down here in the southeast took place--we watched them grow as the days progressed. A lot of my work was down here in extreme southeast Tonkolili, where we were seeing a lot of cases cropping up.

Q: That's the opposite side of the county, is that right?

MARTIN: Yes it is.

Q: How long would it take to get there?

MARTIN: Two and a half hours. This was a painful drive. From here to here, the paved road ended about a third of the way along and the rest was dirt.

Q: From west to east.

MARTIN: It was a two and a half hour drive to get out there. Hold that thought 00:58:00because we're going to come back to that. I will come back to that, but to close this part first, the low-tech process of merely a pen putting dots on a map gave us something which the district did not previously have, which was a clear sense of geographic focuses, foci, where we needed to focus our fire if we were going to identify those cases which were not being reported to us. Obviously, you've got the people who call you, but the big deal if you really want to interrupt the spread is to get people as early as possible in the disease cycle. That would be the ones who haven't called you because they don't feel bad enough yet or haven't called you because they're afraid of what's going to happen if they 00:59:00go in. Heck, I don't know about you, but I deny that I'm getting sick when I'm starting to feel crappy.

Q: Oh, absolutely.

MARTIN: I'll be working on a cold and the symptoms may be unmistakable that, dude, you know you're going to get sick. This is going to get you. And I still pretend that by taking vitamin C and slugging water I'm going to stave it off. We know it's not going to happen. How much more when the disease that you're contemplating could be the end of your life? And worse, but I'll get to the worse in a little while. It's another story. If you want to note, note SDB, safe and dignified burial. We've got a lot to talk about. Anyways, the bottom line being that for what I'm talking about right now, active case finding. We got away from the word "active surveillance," which is a term we would use a lot 01:00:00here at CDC because at least where I was in Sierra Leone, when we used the term active surveillance, people thought that meant yeah, we've got to really get moving and find those contacts. And so they really saw it as just working harder on contact tracing. So I changed the term in my own usage in the districts to active case finding in order to by terminology illustrate no, we do want to find contacts, that's true. We're not dismissing that. But we want to find the people who have not otherwise been detected by the system and identify those cases before they create lots of extra contacts. That process, getting out and getting eyes on the community, was enabled by having this map tool.

Actually, later in the month, I did my old computer geeky thing. I pulled the 01:01:00digital form of that map into a couple of different freeware programs that I had downloaded onto my computer, broke it out into tiles and printed it, stapled it together. And we put a big, as you can see in this picture, it's probably about a 7' x 5' map which we put on the conference room wall, and we started spotting the cases on that during our morning surveillance meeting. The contact tracing fellow I told you about, Augustine, is the guy that you see here in this picture.

Q: Oh, that's Augustine. He's a young guy.

MARTIN: Yeah. He's fairly young. Actually, he is now a survivor because three weeks after I left Tonkolili, he came down with Ebola himself and it nearly killed him. That's probably partially--I told you earlier he was a cowboy. I think he was a little more careless than perhaps he should have been when he was out in the districts. But that's my friend Augustine checking out the map. So 01:02:00that tool, red pen on a map, became a vital part of our low-tech, on-the-ground epidemiology.

Q: This is a stupid question. You're using the red dots on a map. When a case is resolved, when a person passes away or when everyone is cured, what do you do with that red dot?

MARTIN: We never changed that. The map was only the progression of disease. We didn't get that technical. Frankly, it was an indelible marker, we didn't have any dry erasers. I was only there for a month and quite frankly, during that period, we weren't getting a lot of news about disposition yet. The data flow back from--and I need to tell you about the patient flow at some point, but 01:03:00there's a couple things I need to get to first. The patient flow is going to illustrate to you why we didn't actually know what happened usually. We'll get back to that.

I did want to back up because one of the questions you asked a little while ago was about that first day. I don't remember if it was the first or second day, but one of the first couple of days that I was there, we did go out to the field for the first time. We went to Mabamp, that community that I told you already had a lot of red dots on the map, and I actually took a photograph of the village. This is in the village of Mabamp. I did it to black and white for artistic effect, but I think it works. This house you see at the end of a very narrow--do you call it a street, a walking way between the houses is the home at 01:04:00which the index case in Mabamp lived and died. She had gone to Freetown to a funeral. As I'm sure you've heard from some of the others, the process of touching and washing the body at the funeral was one of the major points of exposure. She had come back to her village. She had come down with a fever and the vomiting and everything. Her family had cared for her. She had died and been buried in this village. Before she died, she touched off a chain that we knew to be at least eighteen confirmed cases of Ebola in Mabamp. That was a sobering thing, but this was mostly burned out when I was there.

That day, I think I have that picture in here too, I don't. That day, we also went to the home of a person who needed to be picked up and brought in to an 01:05:00ETU. This was someone who was a contact to a known case. The house had been under observation for a week or two, I don't know. This older woman was very sick, very weak. Had a young child sitting with her who was also very weak; would lay her head on her lap and then get up and be tired and lay down again. That was the time that I first was standing in a village in rural Tonkolili looking at what I could be virtually certain was a person who actually had this virus that I'd been hearing about in science fiction and popular mythos for all these times. As you can imagine, that is a time when your mind is swirling. Again, it's one of those things that as I look back in retrospect feels entirely 01:06:00too melodramatic. That day I was thinking of how to tell the story back to my family and I remember the phrase "six feet from death" was kind of how I characterized it in my own mind. Obviously, we were very careful not to touch anything in the village. We were careful not to touch the people. I knew I was probably walking on dirt that had been soiled by vomitus, diarrhea, whatever. I was in the presence of the Ebola virus for the first time that I knew. What I can tell you now is mostly just that feeling, just that oh my gosh, this is it. This-is-not-a-drill kind of feeling that here, I was seeing this. Now I was just 01:07:00an observer obviously. They were talking to her in the local language. I was brand new. I wasn't really offering much in the way of opinions or guidance or anything. I was really a fly on the wall in this, but I was there, looking at someone who was probably dying from this disease that I'd come to fight. It was a very dark collection of emotions. If that's not the first day, certainly the first couple days I was there.

Q: Do you remember the name of that village?

MARTIN: That was in Mabamp.

Q: Oh, that was in Mabamp.

MARTIN: That was a sobering start.

Q: Do you remember the people you were traveling with that day?

MARTIN: Actually, I think it was probably James and Augustine.

Q: And of course they've been seeing this a lot I'm sure. How did they seem to react?

MARTIN: Oh, they always got much more sober when we were around. The levity was gone. They were all about getting the person to the ambulance, getting them in, identifying household members, contacts, stuff like that. All the levity that was part of the other interactions disappeared when you're in that setting. They had both lost family members and yeah, the mood was definitely more somber with everybody when you were there. In fact, it would vacillate between what I would say was just kind of a quiet resolve and sometimes depending on how cooperative 01:09:00people were about getting in, almost a military kind of a coercive, you're under arrest, you're going to the clinic. There was some of that. One of the things that I think unfortunately was characterized a lot of the national response to Ebola is that quarantine and isolation and monitoring tended to take on a fairly punitive sort of tone that I don't think ultimately was helpful. I don't lay the blame for that at CDC's or WHO's [World Health Organization] or anybody else's feet. I think that was the strong man government exerting. There's a sense of don't just stand there do something and when the main weapon you have is coercion, you're probably going to get coercive in a situation like that, which I think was unfortunate but certainly understandable.

Q: You had mentioned before that there was kind of a mentality with one of the members of your team that it was almost like Cops when they were going out to find somebody. Did you ever get the sense from somebody in the community that they felt like they were being criminalized?

MARTIN: Oh absolutely, absolutely. Especially as the time went on and the house quarantine process got more organized, people frequently complained about feeling like animals in a zoo. That was the term they used because they would have people from all the different NGOs. People from WHO. People from the DHMT. The contacts tracing follow-up people. It was like they were isolated inside their housing compound and wave after wave after wave of people in their Land Cruisers or on their motorbikes would be coming by and talking with them or observing them or doing something with them. People complained frequently. I 01:11:00heard this in multiple different locations about being treated like animals in the zoo.

Q: So how do things progress from the first day?

MARTIN: You kind of hit a rhythm. This is seven days a week, fourteen to sixteen hour days. You get up, you eat, you go to work, you don't have lunch during the day because you don't have time for it and there's no place to go for lunch anyway. You learn to be careful how much water you drink because the only restroom at the DHMT is in the doctor's office and if the doctor is gone and locks his office, you're either going out back or you're not going. You plod through the day. You get done, you have dinner, you have a beer with dinner, you have several beers with dinner, you collapse into bed. You lather, rinse, 01:12:00repeat. You have your debrief time with your CDC colleagues. It was really good that we were at the same hotel with the Tonk and Bombali people because we became a very close team and that time of decompressing with each other was very, very valuable.

Q: Did you kind of compare notes about how things were going in other adjacent districts?

MARTIN: Oh yeah, absolutely we did. Since John was lead in Bombali and I was lead in Tonk, although I only had a small team to lead and part of the time the team was me, we definitely would compare notes and connect things and do what we could to encourage each other, talk through whatever was going on. There was an element of it, was just playing psychological support. There was an element of it which was technical, let's figure out where we need to join forces. Let's 01:13:00figure out where we need to maybe look at the focus a little different. We're doing this, we're doing that, we're writing up that, we're sending this to Freetown. It was a combination of very personal--the boundaries when you're in a situation like that, the personal boundaries disappear. In a situation where you're dealing with a disease whose first symptoms are possibly fever or diarrhea or vomiting or something like that, everybody's personal functions becomes a point of conversation. [laughter] The lines aren't drawn where they are drawn in normal, polite company. Yeah. And you plow through.

In my case, I did not get back to Freetown any time during the whole time I was there. I was there straight through for the twenty-seven of the twenty-nine days 01:14:00I was in-country. I would get out into the field some days, I'd be doing more local stuff other days. Toward the end I was developing some training materials for case investigators, along with the fellow by the name of Joe Jasperse, who was working with Concern Worldwide, which was an NGO that was in Tonkolili. We did not have the big international contingent that came later on. At the time we were there, the only expats were either CDC or this guy from Concern. We developed and gave some training for some newly hired investigators. Got out into the field some more times and did what we could to support the hospital lab people and the district health folks with investigation, with lab data. The 01:15:00normal flow of information from the lab was not working all that well, but God bless the people from VSPB [Viral Special Pathogens Branch] who were running the lab in Bo, which is where our samples were going. Jon [Jonathan S.] Towner, Bobbie [Rae Erickson]. Tara Sealy towards the end. These people were e-mailing me results directly so that I could get them into the response quicker. It was kind of cool. I think it was Bobbie I told one day about how much I was appreciating the fact that she was giving me those results as soon as I had them, meant that I could turn around and give them to the investigators and they could get out about the investigations. That channel was increasing our ability to be quickly proactive. Bobbie's comment to me was thank you so much for saying 01:16:00this, nobody is really acting like we're having an effect in the field. Whereupon, my jaw kind of hits the floor because it's like without their diagnostics, what the hell are we doing, right? Seriously, we desperately needed those diagnostics. The whole response was depending on knowing that this was Ebola and that wasn't. These guys were down there putting in insane hours in difficult environments in this lab that we had stood up in Bo. Thousands of samples they were putting through there and nobody was giving them any love for it. They were a vital lifeline for us.

Q: I think you mentioned that there were some EIS officers who were with you in Tonkolili.

MARTIN: Two.

Q: Were they with you the whole time you were there?

MARTIN: No they weren't. One of them there normal time was Angela [C.] Dunn, who was actually posted to Utah. She was working on infection prevention and control 01:17:00and she was there for about the first half of my time I think. She had gotten there before me and she was done before me. Tushar Singh, the other one who came about the same time I did, got caught up in an unfortunate situation. He's an Indian national and there was a weird thing going back and forth between the EIS program and I think HHS [US Department of Health and Human Services], I'm not sure exactly at what level the back and forth was happening. But the upshot of it was that the Department of State was not willing to guarantee repatriation for our non-US national deployers if they got sick. Given the circumstances we were in, that was not a place where the EIS program was willing to leave people in harm's way. The way they handled it was a little shocking though because they 01:18:00called up Tushar and another young woman, whose name I have now forgotten [note: Bernadette N. Ngeno] but who had literally arrived a day before. I mean we were just giving her her orientation day. And said, you guys pack your bags, get down to Freetown. We're putting you on the first flight home. Boom! Gone just like that. Needless to say they felt, and I think reasonably, they felt rather ill-used by this. Eventually, they got that stuff sorted out. Tushar came back multiple times and in fact now he's on our permanent staff in Sierra Leone. But yeah, they were jerked out summarily, no warning. Boom, they were gone. My last--I think about week and a half in Tonk, I was there alone.

[break]

Q: Was Tonkolili then without some CDC people for a while?

MARTIN: Not for long. They did redeploy--I don't know the exact details because 01:19:00it was several months before I got back, so I'm not sure exactly how it unfolded, but yeah, I think there was at least some break.

Q: So from the beginning to the end of your first deployment in Tonkolili, what kind of change do you see in the epidemic?

MARTIN: By the time I leave, we're still seeing cases going up. We're seeing a much better capacitated investigation group. New investigators have been hired and trained. I actually have participated in training them. We have a much more reliable flow of information from the lab to the district. We have at least some understanding of the--getting eyes on the district, doing active case finding. We have this process of assessing the location from which the cases are being 01:20:00covered has become a standard practice within the DHMT. So this idea of focusing regions as necessary has been pretty well ensconced in DHMT behavior by the time I leave. So those are the places where I see impact after my month.

On a more personal note, about three days before I leave the country, in fact my last day in Tonkolili I think before I took the car home the next day, one or two days before I go, I'm out in Masokory, which is that area to the southeast. Here's where I need to back up and tell you that story I told you I was going to tell you. If a person comes down with Ebola symptoms, the fever, the diarrhea, the whatever, they're called in by themselves or by some other person to either 01:21:001-1-7, the national hotline, or somebody calls somebody directly at the DHMT. DHMT dispatches an ambulance to pick them up and transport them back to the holding center, which is at Magburaka General Hospital there in the seat of the district. Remember I told you it was a two-and-a-half-hour drive one way to get out there. Well, it's two and a half hours for the ambulance too. Ambulance gets out there, picks them up. Probably picks up more than one person because a drive like that you're going to conserve resources as much as you can. The driver is in full PPE. The attendant is in full PPE. They're getting these people into the ambulance. These people are sometimes too weak to get into the ambulance by themselves. They're really struggling, some of them. Now they're going to take 01:22:00this bumpy two-and-a-half-hour ride back to Magburaka, feeling crappy. If anybody is vomiting or having diarrhea, that's spreading around the back of the ambulance. If one of the people we picked up actually turns out not to have had Ebola and the other one does, guess what? They're all exposed by the time they get there. They get to the holding center. At the holding center, they're going to be put into the isolation ward. Their blood is going to be drawn, it's going to be sent to Bo. That's a three-hour drive away. It's probably going to actually not go until the next morning. It's going to take a day for the folks at Bo to run the lab. In the best of times, depending on when the samples got sent, the people at the Bo lab are going to have called me with results or e-mailed me results by that evening. Twenty-four hours on from when they got in. If sample timing got messed up or anything, it can be as much as forty-eight hours. Meanwhile, the person has been sitting in the holding center with other 01:23:00people who have Ebola. If their test comes back negative, they still had the ambulance ride. They still had the holding center. These people are contacts. We've got to monitor them for twenty-one days because they may have gotten it. They may have been exposed in the past twenty-four to forty-eight hours. If they have Ebola, the nearest treatment center is Kailahun [District], nine and a half bumpy, miserable hours' drive away.

Q: Kailahun, the district in the far east of Sierra Leone.

MARTIN: Yes, that's right.

Q: And Tonkolili we're talking more central.

MARTIN: Tonkolili is smack dab in the middle of the country. They're going to Kailahun for treatment. I talked to an MSF [Medecins Sans Frontieres] doctor who worked in Kailahun. I actually sat next to him on the plane home that time. It was not unusual for them to open the doors of the ambulance and find a corpse. If you survived, then you went through ten days to two weeks of hell during the 01:24:00time you were in treatment because once you actually had symptoms of Ebola, you had about two weeks. You were either going to be getting better or you're going to be dead. Obviously, plenty of both happened. Of those who got into the treatment center, slightly more than half survived, but a lot didn't. All that to say that the person who actually contracted Ebola in a rural place like Sierra Leone went through a lot of really miserable time before he or she either died or recovered. So, I say that to say, the last time I was in Masokory, down there in the southeastern part of the district, we were there because we had 01:25:00continued to see more cases cropping up and I said to my team, you know, we ought to pay another visit there and get our eyes on how the district is going. Encourage the investigators out there and so on, because we clearly still have active disease. An ambulance rolls into town, but it's not to pick people up. This ambulance is coming back from Kailahun with five survivors in it who are being brought back to town. I get the privilege of watching these survivors get off the ambulance and be welcomed into the village. I have that on video and the museum has that too. I got to see these people being welcomed by their husbands and their families--this was all women--back into the village after having gone 01:26:00through all that hell that I just told you about. Now, the same day I also saw two more patients, maybe three, be transported to the holding center. One of them is the little girl that's in that picture that is now in the CDC [Public Health] in Action [photography contest] that was one of the first-prized pictures.

Q: Yeah, I remember that.

MARTIN: That same day in Masokory, I took that photograph of that little girl who is probably no longer living, I'll never know. And I took the video of the survivors getting off the ambulance and going into the village. As they're being welcomed with great glee back into the village, one of them gets up to her house and collapses and just bursts into tears and collapses on her stairs. Augustine tells me two people went. She went with her daughter and her daughter's not 01:27:00coming back. [pause] Obviously that still affects me. That kind of joy and sorrow, pain and agony and rejoicing and goofing off, that cognitive dissonance was my experience in Tonk.

Q: You hear a lot of stories about, and it really was awful when it happened, the stigmatization of survivors. But what you saw that day is people getting off of an ambulance and being greeted with joy.

MARTIN: Yes, welcomed with open arms. The stigma is a real thing and I would 01:28:00never discount it. I saw plenty of it. I didn't see it that day. In fact, while we were in the village another woman who was a survivor from Kailahun had come back earlier, ran back to her house to get her discharge certificate and came and showed it to us, and this is her. This woman on the left here, she's holding a certificate of discharge, which the version I have on the tablet is too low-res [resolution] to show this, but the version of the original picture, which again the museum has, you can actually read the certificate. It says that she has been successfully treated at the Kailahun treatment center, that she is no longer a risk to her community, that she can engage in normal activities. I forget the exact wording, but it's actually fully legible in the photograph. 01:29:00This is in the same village as the ambulance where the people are getting off and as this little girl who was waiting to be transported to the treatment center.

Q: Lying down on a bench.

MARTIN: Those three photographs were taken within less than an hour of each other. That's what it looked like and that was just my first time.

Q: Now I have some notes down for some things to mention to you. I don't know if they're relevant for this first trip or not. First is SDB, safe and dignified burial.

MARTIN: That's an overall. It's not just the first trip, that's an overall story about the response.

Q: Sure. And the second, patient flow? We've just kind of gone over it.

MARTIN: That's the story we just went over. That's the many hours of horrible roads.

Q: Travel. Nine hours to Kailahun.

MARTIN: Yeah. During the time I was there, the British military was building a new treatment center along the road between Magburaka and Makeni. It was actually in Bombali district, just barely inside the edge, and I was watching it go up. I believe it opened either two or three weeks after I left. Suddenly, that horrible run to Kailahun was over. That treatment center was a godsend to the people of Bombali and Tonkolili because it allowed them to have treatment without driving nine hours. One of the terrible tragedies about the situation like that too is, and this maybe segues into some of the issue overall about burials. It's way too risky to transport the body of someone who has died from 01:31:00Ebola back to their village. I mean this thing is a hot, steaming pile of virus. People who died in the treatment centers were buried in graves near the treatment center, which in a culture where death and dying is so much about village and family, these people might as well be buried on the moon. Their families aren't there. No one can visit the grave. There is none of the traditional accoutrements of an appropriate sendoff for the person because they died and were buried. In many cases the villagers never heard what happened. Now that goes into the larger picture of the burial situation.

I always want to preface this by saying it's really, really easy for Westerners to get this notion of benighted, primitive people who just don't do what we do because they don't know any better. Nothing could be further from the truth. If we think about it, every culture very much including our own has got rituals and ceremonies and practices around death and dying, even the atheists still have practices around saying goodbye to their loved ones. They may not believe that they've got any kind of beyond-death impact, but there are ways in which you appropriately grieve and honor a person who has passed, and that's true no matter what your philosophy, your religion or lack thereof. For anybody to write this kind of stuff off as primitive or benighted because it's not the way we do 01:33:00things, just gets my hackles up.

With that preface, the practice in Sierra Leone, heavily influenced by the animist traditions that predate any external religion, but still by and large practiced by those who've adopted either Islam or Christianity as well. There's been some mishmash on exactly how the ceremonies have merged, but the bottom line is that when someone dies, it is important that their close family be involved in bathing the body, dressing the body and preparing them for burial. In Islam, wrapping them in a white shroud. In Christianity often also, but the white shroud actually comes mostly from Islam. Burial very quickly after death. I learned recently from one of my Muslim friends in Sierra Leone that the ideal 01:34:00in the Muslim tradition is actually that--you know that in Islam there is the five times a day that you're called to prayer. In some of the more conservative Muslim traditions, you should be buried not later than after the second call to prayer after your death. So we're talking within hours. This I only learned literally when I was in Sierra Leone this past month. I did not know that before. Prompt burial with the appropriate rituals and sendoffs are important. In some of the more animistic traditions, there would have been a time where the body was kind of like--viewing. Family members would touch the body, embrace, kiss them goodbye, so on. There's a variety of contact. Obviously, these things 01:35:00are hyper-dangerous when the body's infected with the Ebola virus. That's a biological fact. We, and by "we" I don't mean just CDC, I mean CDC, the national Ministry of Health [and Sanitation], World Health Organization, anybody else who was involved in the process of Ebola control, dictated that the way to safely--the key to stopping the epidemic was safe burials. Safe burials being defined as you really can't touch the body without full PPE. You definitely don't have family members touching the body. They're going to get sick if they do. You bury them in a sealed body bag so that the fluids don't contaminate the surrounding area and increase the likelihood of infection to somebody else. That 01:36:00violates so many of the mores around death and dying for the Sierra Leoneans. It's like if you tried to make it worse, I'm not sure what you would do. Full PPE means they're in these weird, white, alien-looking suits. You can't even see their faces, and actually people mentioned specifically they can't even see their faces as one of the objections. It did get worse at one point when they ran out of the one kind of body bags and the replacement body bags were black instead of white. White is a very important burial color in especially Islam, but also the others. But buried by non-family members. You can't see who they are. The family's not allowed to touch them. They are buried far away from home. The burial rituals are not observed. At some point when they realize how much 01:37:00people were resisting to this, they tried to add "dignified" to the process, calling it "safe and dignified burial." And by dignified they meant that the family and the religious leader of choice were invited to come and stand at a distance and observe the burial and say prayers, do whatever they wanted, but not get close to the grave. It was an attempt, I'll grant it was an attempt, but I know for a fact, both from conversations with individuals but also from some anthropological reports that I read, that one of the reasons why people hid their illness, fled into the bush, hid contacts, ran away, did whatever else they did to resist being taken for treatment was that they did not want their bodies to be handled in this way. I have a report on my laptop done by one of 01:38:00the WHO anthropologists who interviewed a family where the father literally made his sons promise that they wouldn't bury him in one of those awful body bags. When he was buried in one of those awful body bags, the family came back with their pastor, exhumed the body, dressed him in his own clothes and laid him on top of the body bag, back in the grave. But let's think about this from the point of view of what they were growing up with. We say that that's the safe burial because if you touch that body you're going to get Ebola. The animist traditions with which they have grown up for hundreds of years say that if you do not give that person the proper sendoff, one, their afterlife is compromised, possibly seriously, and two, they may come back and haunt you. Now you tell me 01:39:00which is the safe burial. The one where you might get Ebola or the one where you will be haunted by the ghost of the person? The problem is, our calculus doesn't take all the variables into account here and obviously I get a bit exercised about this.

By dictating this extreme burial practice that we did, and again, I say the large we. This is not just a mea culpa for CDC. We cannot know how many people were exposed to Ebola because of their avoidance of the intervention because we did not completely characterize the motivators for and against the intervention. 01:40:00We have in CDC's own history of practice, and I learned this in STD, remember this is my first job was VD control. When you're trying to get a woman who prostitutes herself in order to get money for her crack addiction to be less at risk for syphilis and HIV [human immunodeficiency virus] and everything else than she is right now, you don't talk to her about chastity. That's so far from her world you're just never going to get there. You can't get from Point A to Point B. You talk to her about harm reduction, and "harm reduction" is the public health term we use. Harm reduction strategies are negotiated strategies where I sit down and I learn what drives you. I learn what your fears and your 01:41:00motivators and your concerns are and I work with you in an equal-to-equal negotiation about how can I help you apply what I know about biology to what you're telling me about your life in a way that you'll at least be at less risk afterwards than you were before. In some of my patients in STD in Los Angeles, that was consider only having sex with the people whose names you know and literally, that was a harm reduction step for them. Now, does that completely stop disease? No, it doesn't, but it may stop the rampant spread of the disease. I believe that we as a public health community needed to bring that approach to the handling of the body in Sierra Leone and we didn't. What might it have looked like, I don't know. I have some ideas. Washing the body is part of the 01:42:00ritual in most of these things. I do know for a fact that some of the senior imams, the Muslim leaders in Sierra Leone, publicly declared that adding chlorine to the water with which you wash the body is halal, is still blessed, is still holy, is still acceptable within the Muslim practice. That, as far as I know, was a unilateral thing they did on their part. Could we have negotiated where the people who were doing the preparation of the body at least wore gloves? Maybe wore gloves and a gown and made sure they used chlorine in the water while they washed the body? Maybe. Last time I saw, not too many dead bodies spit. I don't think the face shield and the face mask for handling the dead body were frankly all that necessary. This head-to-toe space suit shit, I 01:43:00get it when you're dealing with somebody who may projectile vomit. I'm not convinced when you're dealing with a corpse. Would it have eliminated the risk? Would it have eliminated all the risk that the full PPE did? No, probably not, there's still some. Would it have reduced the risk enough that we might have had people willing to engage the system instead of running into the bush? I bet that it would have. One of the things that I am continuing to advocate with my colleagues at CDC and I really, really, really hope I can someday get some traction on is that we need as an agency to become far better at respecting the non-scientific elements of what drives people. I've seen this in other areas. As an agency, we tend to think that we are the scientific experts. We come up with the recommendations, we come up with the guidance, and then we approach the 01:44:00social scientists, the social mobilizers, the health educators, the communicators, the thought drivers in the community; we approach them to get them to take our message to the people. We don't engage them in the development of the message. That is I think our religious blind spot as an agency, is that we fail to recognize that our own scientific, secular bias with all of the strength that it has, is not the only and sometimes not the major thing that will influence people's behavior. Until we're willing to come to terms with the fact that people are far more complex than their biology and their psychology, 01:45:00we're going to continue to have areas where I think we probably exacerbate the problem we're trying to solve. So that's my soap box on safe and dignified burial.

Q: I appreciate hearing it.

MARTIN: I notice that we've already used up two hours, and we could go on for I don't know how much longer, but I've got a guy who wants to meet me.

Q: Do you? I can do this all day. When are you needing to be out of here?

MARTIN: Actually, I need to meet this guy in the next couple minutes. I've got a lunch meeting with him.

Q: Do you want to continue like a couple weeks from now?

MARTIN: I do, I do. I think there's more I would like to share with you.

Q: There's more that I'd like to hear from you. I think we're comfortably at about the close of the first deployment.

MARTIN: Yeah, this is a good--the only thing that we might put a placeholder on 01:46:00for the first deployment, and in fact I can just say real quickly. You mentioned about stigma earlier.

Q: Yes.

MARTIN: I was there during the midterm election and as I'm sure you remember, there were people who, as a rule, tend to find that fear increases their votes, who found Ebola and the fear thereof to be a useful vote increaser during the election. It felt really frightening to those of us who are across the pond who genuinely wondered whether we were going to get home and be thrown into quarantine somewhere and not even allowed to come see our families. Fortunately, I came home a couple days after the election. Things got really quiet on November 3rd. I didn't come home until like the 15th or 16th, so I was not quarantined, but it was a very real concern of all of ours then. What are they 01:47:00going to do? One of my friends was going to be presenting at the APHA [American Public Health Association] conference which was in New Orleans, and got a notice from the New Orleans State Health Department that says don't even bother coming. We will lock you in your hotel room. But for me, when I got home, I actually e-mailed the pastor of our church before I got home. We have a fairly conservative group in my church, so I knew that was a possibility. I said, "I don't want to create an issue for people. If it would be more comfortable for me to just lay low for a couple of weeks, I'm not going to make an issue out of it, just let me know." He e-mailed me back two days later, he said, "I've talked to every doctor in our congregation and I've talked to the elders. We want you back." When I got there, if there was anybody who was afraid and hanging back, I 01:48:00wouldn't have seen it for all the people that were coming up to give me a hug and welcome me home.

I got into my office here at CDC and you may recall that the woman who was the union steward here was raising holy hell during that period about how we should keep all of our deployers home for three weeks because they might make the poor, innocent people who never deployed sick here at CDC. She was raising Cain about it. I got into my office and people that I rarely ever did more than say hi to had come up and give me a hug and welcome me home. People were going out of their way to demonstrate, to me at least, that they were not willing to allow that to drive them. So, while I have plenty of friends who experienced very real stigmatization when they got home, my experience was exactly the opposite. It was really, really a positive experience. And yeah, that puts a good coat on 01:49:00deployment one.

Q: Thank you so much Dan. Maybe when we return we can talk about the process of re-acclimating to being here and how you change after that first deployment and what happens then.

MARTIN: There's definitely plenty to talk about there. Thank you Sam, this is a privilege. It's a privilege for me to get the chance.

Q: Privilege for me to hear it.

END