Dr. Eric Halsey

Dr. Eric Halsey

Q: This is Sam Robson, here today with Dr. Eric Halsey. Today's date is February 8th, 2018, and we are in the audio recording studio at the CDC [United States Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Dr. Halsey as part of the CDC Ebola Response Oral History Project, which we are doing for the David J. Sencer CDC Museum. Dr. Halsey, it's really great to have you here, thank you for being here. Could we start out with you just saying, "My name is," and then pronouncing your full name?

HALSEY: Sure, my name is Eric Halsey.

Q: Great. What's your current position at CDC?

HALSEY: I currently work for PMI, which stands for the President's Malaria Initiative. I'm in the CDC Malaria Branch in the Centers for Global Health. What I do, I work in Africa, and I work primarily in five countries helping with case management. The case management of malaria includes the treatment, but also the diagnosis of malaria as well. Those countries where I work currently, primarily, are Liberia, also Zambia, Zimbabwe, Mozambique and Angola. However, PMI is in 00:01:00twenty-four countries in Africa, so all of us--and there are about twenty of us at CDC who do this--have some sort of involvement in all of those twenty-four countries. In addition to those countries, there are also some countries in Asia as well.

Q: Thank you for the succinct response. That's awesome and I look forward to getting into more of that. If you were to tell someone in just a couple of sentences what your role was in CDC's Ebola response, what would you tell them?

HALSEY: That would be hard to do in two sentences because I actually went twice. I went to two different countries, and the first country I went to was Liberia. That was in late March of 2014, and that was actually not for Ebola. I was going over for malaria work, and it turned into an Ebola trip because I was there for the first announced case in Liberia. Already I'm over my two-sentence limit, but 00:02:00I also went to Sierra Leone, and that was in January of 2015, and that was part of the Ebola vaccine response, so preparing in the country for an Ebola vaccine trial.

Q: I'm going to take us back in time, if that's cool with you. Can I ask when and where you were born?

HALSEY: You can ask. I was born in Baltimore, Maryland, and when? So, 1973. After Baltimore, Maryland, I quickly lived in Virginia, South Carolina, Oklahoma, and then ended up in Kansas City, Kansas, about age five or six. That's where I ended up going to all of my elementary school, kindergarten, up through age eighteen. Even moving past that, I ended up going back to Baltimore for undergraduate school at Johns Hopkins University. I stayed there for four years and then came back to Kansas, went to medical school in Kansas City, Kansas. That was for four years, and that was with the [US] Air Force, they paid 00:03:00my way through school there. After completing medical school in 1999, I ended up doing a residency and internship at Wilford Hall Medical Center in San Antonio. And even after that, two years of infectious diseases fellowship training, also in San Antonio.

Q: In those first five years when you were moving about the country, what occasioned that?

HALSEY: I'm the son of a professor. My father was a microbiology/immunology professor, and he was doing a post-doc [post-doctoral research fellowship] in a couple of those cities. Ended up being a professor at the University of Kansas after doing some post-graduate work at these various universities in Virginia, Oklahoma, South Carolina.

Q: Can you tell me what it was like growing up in Kansas City, Kansas? I don't know too much about it.

HALSEY: When people hear about Kansas City, Kansas, they think, that's in Kansas, there must be lots of cows. Maybe you pick some wheat on the weekends. 00:04:00But Kansas City is like any other big city, it's very similar to Atlanta and Baltimore, any other big city like that. Professional sports teams, lots of nice restaurants, a very relaxed, great place to raise kids. It still ranks very high when you see these indices of where you want to raise your kids. A very nice Midwest feeling to it. Certainly, it's a palpable feeling, a perceptible feeling compared to maybe going out to Baltimore for example.

Q: As the son of a microbiologist professor, did that spark your interest in science and heading toward the medical direction, or what was it?

HALSEY: Good question. I don't know--I mean, it must have in some sort of subliminal way, as much as I probably tried to resist it, as many of us would as 00:05:00kids. But I also think, besides just being influenced that way, maybe I just inherited the gene. What do they call it, the two different forces, nurture versus nature. It's probably a little bit of each at work. But actually, when I went to Johns Hopkins undergrad [undergraduate school], I was thinking, maybe I'll go into engineering. I did biomedical engineering as my major, which actually opened up the possibilities both in the engineering realm as well as the medicine realm. By the time I finished, it was very clear to me that I wanted to go into medicine, and so, in fact, I applied early and got into school at the University of Kansas.

Q: What made it so clear that medicine was what you wanted to go into?

HALSEY: I think a lot of it had to do with just being at Johns Hopkins, and it's one of the epicenters of medicine, of medical technology. We'd have professors 00:06:00come in to tell us about the latest with HIV [human immunodeficiency virus] or cancer diagnosis and treatment, and it was very easy to be swept up in that and to be excited by that. In all honesty, I really was swept up in that, and even to this day, I feel like medicine is a very interesting field to be in.

Q: Coming back to Kansas City for the MD [doctor of medicine degree], was it because it was home?

HALSEY: It was because it was home, without a doubt, yes.

Q: Did your father still live there?

HALSEY: Certainly, they were still there, and many of my friends when I was growing up. It was just a familiar atmosphere for me, and it was actually a very good education for me as well. In fact, while I was at Kansas as a fourth-year medical student--so in my last year of medical school--it was the first time I had ever travelled out of the country. I travelled to Kenya, and this was for an elective. They offered international electives to many of their students, so I 00:07:00got to go to Kenya. It really was a life-changing event for me, spending four weeks out, and we worked in an infectious diseases ward in Nairobi, and every day, seeing cases that you would dream to even read about in a textbook. At that point, I knew I wanted to be an infectious diseases doctor.

Q: What kinds of cases are we talking about that you would see?

HALSEY: Everything. By far the most common thing I saw was HIV. I was working at Nairobi Hospital, or actually Kenyatta [National] Hospital and Nairobi Hospital. Kenyatta Hospital was a place that anybody could go to, and wards were overrun with HIV-positive people. Oftentimes, there would be two or even three people in a bed, and these are people with very low immunity, very low CD4 [white blood cell] counts, and this is 1998, almost 1999. At this point, the US was kind of getting in front of the epidemic, but it still hadn't happened in Africa. Maybe, 00:08:00just maybe, five percent of the population was on effective antiretrovirals, but most weren't. You would see people coming in with end-stage HIV diseases. It was very awakening for me.

Q: Are there any patients who even now stick with you, in your memory?

HALSEY: Certainly, many, many from that period. It's strange that you would ask, and I'm sure there are many months that I probably don't remember from my internship and my residency afterwards, but I do remember somebody who had very low CD4 counts. He had all these swellings in his neck and kind of in his lymph nodes. It looked like it was probably some type of lymphoma, but you didn't really know for sure what it was. The diagnosis of lymphoma is to do a bone marrow biopsy, but this is a very--it's a very intense procedure where you've 00:09:00got to take an extractor and pretty much put it into somebody's bone. In the US, maybe, I had done this one or two times on the wards, but it was always right here in the hip bone, in kind of the pelvic area. But in Africa, they did it a different way. My attending came to me and said, "You're a trainee with us, it's your turn to do a bone marrow biopsy. Would you like to do this?" And when we did wards, we'd have twenty people with us, so of course I'm like, "Sure, that would be an honor. I'll need some assistance with this, but I'll go ahead and try that." Well, it turned out that they do bone marrow biopsies from the sternum. All of a sudden, fifteen minutes later, I've got this very sharp extractor tool that I'm digging into this guy's sternum to try to get bone marrow out of. Right behind somebody's sternum, as you know, are his heart and lungs, all of these things that you don't want to puncture. Certainly, an experience that I had never or I have not forgotten since then. Fortunately, it 00:10:00went well for the biopsy. I can't comment on how well the patient did, I was only there for a few weeks and wasn't able to follow up.

Other experiences I remember from that period of my life, people would die every day. As I said, I was on a ward, often beds--there would be eight beds in a room, often two people in each bed, sometimes people on the floor. Some of these people most likely had tuberculosis, there wasn't any sort of precautions, respiratory precautions going on and oftentimes, we would discover who had passed away on our morning rounds at seven thirty, eight o' clock in the morning. One of the mornings, when I showed up, when I was downstairs--and I was working on the third or fourth floor--I could hear a woman howling, just howling at the top of her lungs. As I walked up to work, the howling got louder and louder and louder, and it turned out that she was the mother of somebody who 00:11:00passed away just a couple of hours before I showed up to work. She was walking the halls, crying at the top of her lungs. It was mortifying to hear and to experience. I think she was Kikuyu, and I think this is the way that they--

Q: Grieve.

HALSEY: Yeah, the way they acknowledge death. But it was a difficult experience to go through.

Q: You've talked about this experience also as a really formative one for the rest of your life, can you elaborate a little bit?

HALSEY: Yeah, it was so life-changing, just because I had never been out of the country before, and now to work in this hospital and to see these HIV cases--but not only people with HIV, we'd see very strange infectious diseases. In medical school, they always talk about horses and zebras. I don't know if you're 00:12:00familiar with this saying, but they say if you hear hoof beats, always think horses, don't think zebras. In other words, if you're working an emergency room in the United States and somebody comes in with chest pain, you shouldn't be thinking it's some sort of strange parasite from Asia. You should be thinking, it's common, like horses are common. You should be thinking of a heart attack or pneumonia or what-have-you. But I always loved to think about zebras. [laughter] All of a sudden, I'm in Africa, and everything is a zebra. I'm not just talking the animal, but every disease that may get only a paragraph in a pathology book for a medical student, all of a sudden is a very common entity. It just blew me away. But also what blew me away is how treatable and preventable a lot of these diseases are, and this is one reason we don't see them in the United States and why we'd see them in Africa. They're diseases of poverty, of substandard housing. It just changed my world view. I've always been kind of on that track 00:13:00ever since.

Q: Had you known that you were going to continue and do an infectious disease fellowship, like before the trip?

HALSEY: No. In fact, I was thinking about possibly neurology, maybe anesthesiology. When people go through medical school, their thinking often evolves. Very few people end up graduating with what they thought they were going to do on day one. Even in my third year, and maybe even early in my fourth year, I still wasn't sure. Fortunately, I did this rotation very early in my fourth year. At that point, it was clear to me that this is the path I need to take. That path, after I graduated from medical school, was internal medicine for three years and then a fellowship in infectious diseases. And then even beyond that--so most people do infectious diseases, but it's very domestic oriented. I always tried to get an international flair to it. Every time I had 00:14:00an opportunity to work overseas, whether that was Africa or Asia or South America, I always hopped on that and really cultivated that interest that I first had from my Kenya experience.

Q: Can you just mention a few of those other places where you went and what you did there?

HALSEY: Oh sure, and there's a laundry list of them. After Kenya, very quickly I signed up for medical missions in Dominican Republic--that was still in medical school. Once I joined the Air Force--so the Air Force paid my way through medical school, but once I actually started working with the Air Force, which was after medical school, in San Antonio, there are often opportunities through the Armed Forces because they are in many different countries and they are often doing humanitarian goodwill missions to different places. In addition to that, they have lots of training opportunities as well. When I was in San Antonio doing my internship, residency and fellowship, I ended up going to Thailand 00:15:00twice. Part of my fellowship in the Air Force was going to Cairo for four weeks. Shortly after finishing fellowship, and now I'm a full-fledged doctor stationed in Ohio, I ended up doing some HIV trips to South Africa where we would work with their government, we'd actually work with their military, training their doctors how to treat HIV. I'd go over to these places in South Africa, and just like in the US, I had this very small panel of maybe twenty to thirty HIV-positive patients, and almost all of them were very well controlled. It was almost not like even treating HIV-positive patients. It was kind of treating young people and just making sure that they're on their regimen. All of a sudden, I'm in South Africa and I'm seeing twenty patients a day, almost none of them are well controlled, and I'm here with this very junior, South African doctor, who in most cases is just out of medical school, who is looking at me 00:16:00for guidance. All of a sudden, we're kind of both learning all of this together. Twenty patients a day, very sick--at the end of the week, I'm seeing ninety to one hundred cases. Very tired, but also very, very interesting and also very worthwhile. I ended up doing two of those. I also did a trip to Sierra Leone, where I lectured on HIV. As my time passed in Ohio, I ended up doing more trips to South America where we did humanitarian missions to Bolivia, and that was up in the highlands of Bolivia, fourteen thousand or twelve thousand feet. It was on Lake Titicaca. Then my next trip to Bolivia was actually on the Amazon. We were on a river boat going down the Amazon. Then, after that, I did another river boat trip in Peru, passing out medicines and vaccines and that sort of 00:17:00thing. That actually developed my interest in working in South America. In 2009, I actually moved to South America, where I lived for four years, and worked for the Naval Medical Research Unit, Number Six [NAMRU-6]. I was head of the virology department there and did lots of work on mosquito-borne viruses, as well as respiratory viruses. But really, the main focus was on diseases such as dengue virus, Mayaro virus in the Amazon basin area.

Q: I always ask this when I hear that somebody worked at a NAMRU--did you ever overlap with Joel Montgomery?

HALSEY: Oh sure.

Q: You did?

HALSEY: Oh yes. Yes. And now we overlap here, too. Joel was there when I came in 2009, so I think he had already been there for maybe two years. I think we both were there for two years, together. He was there from I think 2007 to 2011 plus 00:18:00or minus, and I was there from 2009 to 2014.

Q: Right. Did you ever work on similar--on the same projects, or were you separate a little bit?

HALSEY: Mostly separate. I think we may be on a couple of papers together from our time there because he was very interested in respiratory viruses like influenza, and somewhat--I think he was interested in actually a lot of things. He led the Emerging Infections Program, so they got to dabble in lots of things. We had many chances to work together.

Q: It's cool that two of the early Liberia people also happened to be at NAMRU-6.

HALSEY: We found that kind of strange, too. As well--I think we're going to go into it--I was really the first one from Atlanta, from the CDC, to be in Liberia, but the second person was Joel.

Q: Right. Wow, that's so wild. I didn't ask before, and I want to, about your decision to go into the Air Force. What prompted that?

HALSEY: It was purely financial. They paid my way through medical school, they 00:19:00paid for books and an apartment and all of that. It's a fairly common program, it's still going on today, called the HPSP program, Health Professions Scholarship Program, I think, where they'll pay for medical school and in return, you owe them year-for-year how much they paid for. I owed them four years after my training, so that's not after med [medical] school, but that's actually after residency and fellowship. I owed them four years. I think I ended up giving them ten.

Q: Wow.

HALSEY: Yeah, and many people get out the day that their commitment ends, but being an infectious diseases doctor in the military is not such a bad thing. Lots of interesting opportunities like we've talked about, going to Bolivia, Thailand, Egypt, South Africa, and to get paid for it. As an infectious diseases doctor, you could still do this as a civilian, but you're going to do it with your two weeks off every year and not get paid for it.

Q: What was it like living in South America?

HALSEY: It was fabulous. NAMRU-6 was one of the highlights of my life. Prior to that, I was purely a clinician, so ninety-five percent if not more of my day prior to that was taking care of patients and educating residents and interns and that sort of thing. Moving to Peru, working in Lima as well as Iquitos, as well as actually all of South America, I had almost no clinical duties. I put on the researcher hat and learned the trade as quickly and as best as I could. It was quite an education, and it really paved my way to where I am today here at the CDC, just in how to think about public health, how to approach epidemiology. It was all on-the-job training for me, but it was fascinating to do.

Q: Was it ever a rough transition? Did you ever miss treating the patients?

HALSEY: Certainly. That just becomes part of your fiber, your core. After doing it for four years in med school and then residency and then doing it for five years as a staff doctor, at least with many people, it kind of becomes their persona, and it really was mine, even when I wasn't doing it in Peru. Even when I'm here at the CDC, in fact, I feel like it's so much of my persona that I've now actually started to volunteer. I work twice a month, for free, in an infectious diseases clinic at the VA [Atlanta Veterans Affairs Health Care System]. It's totally, totally worth it because it really has reenergized and reinforced the way I feel about myself and this important part of me that was almost atrophying for a while.

Q: Going into the more public health and looking at the larger populations, how did your thinking on that evolve? Was that exciting? What did you think?

HALSEY: That was a slow evolution too. Going from being a clinician, where you're just seeing one person at a time--or at the very most, like a small outbreak--you're very focalized. And then moving to Peru where we were doing research, but it may not always be research on an entire population--it's often a group of people that you select to do a study on. Then coming here to the CDC, which is really the epicenter of epidemiological work in the world. Every step of the way you gain a new perspective, and I'm just very fortunate to work around a lot of people who can help me fill in the gaps where they need to be.

Q: So it was 2014 when you left Peru, is that correct?

HALSEY: Correct. It was January 2014. I moved here to Atlanta the week of Snowmageddon. I think it may have been the second or third day that I worked 00:23:00here. I think Atlanta got pummeled by maybe two inches of snow and stranded people on the highway for seven hours. I don't know if you were here at the time, but it's an event that they're still talking about even four years from that day, and that was my first week here. I wasn't stranded, fortunately.

Q: You didn't take to the highway?

HALSEY: Fortunately, I did not have to take to the highway, [laughter] but it was quite an interesting learning event about Atlanta life.

Q: That's an amazing introduction to Atlanta. What occasioned you coming to Atlanta?

HALSEY: It was a confluence of a lot of things. One, just being in Peru for four or five years, many people only stay three years, so I had to beg for a fourth, and almost begged for the last half of that. I was there for four and a half years total. It's a very nice position, so other people were interested in 00:24:00taking my spot, and I had already been there for way too long, so that was one reason. My wife also was very eager to get back to the US where she could work as she was trained. The CDC provided a lot of nice things, or even Atlanta provided a lot of nice things for the two of us both being professionals. The CDC obviously provided something to me in infectious diseases--I changed uniforms from the Air Force now to the Public Health Service. Many of the other possibilities didn't have all of these potentials that Atlanta had for both me and my wife.

Q: Can you describe the work a bit? What you were initially focused on in January 2014?

HALSEY: Sure, sure. When I joined the CDC, I was still with the Malaria Branch as I am today, and my concentration at that point was still as the lead of the case management program in the President's Malaria Initiative, PMI. So PMI is 00:25:00approximately a $675 million dollar initiative, annual, that gives money--well, that co-manages money that we give to African countries, as well as a few countries in Southeast Asia. My concentration was mostly on the treatment and diagnosis of malaria. All of us also concentrate on countries as well as these disciplines, and so initially when I came to PMI at the CDC, I concentrated on seven countries in West Africa, of all places. Nigeria, Ghana, Benin, Guinea, Liberia, Mali, and I'm forgetting one of those. Many countries there, and that actually was the reason that I ended up in Liberia in late March 2014.

Q: Twenty fourteen, oh my God. Can you just describe arriving in Liberia and 00:26:00your first little stretch? How long were you there before getting the call that Ebola had hit?

HALSEY: I got the call even before I landed.

Q: Oh, you did?

HALSEY: The whole story of my trip, my first CDC trip--so I started at the CDC in late January, and it took all sorts of maneuvering to even get visas and approval for me to travel in late March to this fairly essential malaria meeting that was happening in Liberia. Keep in mind, at this point, the CDC only had one permanent staff in Liberia. Now I think they have dozens, post-Ebola. But at this point we had one staff, Christie Reed was her name, and she was a physician concentrating on malaria, so she worked for PMI. I was scheduled to go out and visit with her and put together, with a few other people, something called a malaria operation plan. Essentially, this is how PMI will support malaria 00:27:00control efforts in Liberia for the next year. The plan was to go out there for two weeks, we'd talk with people in the National Malaria Control Program, talk to implementing partners who help us, and just talk amongst ourselves about the best way to spend the budgeted amount of money for Liberia. That was the plan.

This was in March of 2014 that I was scheduled to go. In early March, we started to hear reports of maybe some cases of Ebola in Guinea. As an infectious diseases doctor, I've heard about cases here and there over the last ten years, some in Uganda or Democratic Republic of Congo, and most of them followed the same script that it hits a village, often a remote village, has a very high case fatality rate, and then it kind of burns out after it kills anywhere between a 00:28:00dozen to three to four hundred people. That was kind of my view of Ebola at that point in my life, and this is March 2014. I heard of these cases in Guinea in early March, and said oh yeah, Guinea is actually a country that I'm working in, I haven't been there yet. Liberia is a bordering country of Guinea, that's kind of interesting. But we've never really heard of Ebola being transmitted across borders on a large scale before, so it was just kind of an interesting thing to note.

Q: I'm sorry to interrupt. When you say that you started to hear a few things about Ebola possibly being in the region, how were you hearing these things?

HALSEY: The Guinea reports were on the news, but when I say they were on the news, they may take ten seconds of a thirty-minute NBC [National Broadcasting Company] broadcast, or just in passing reference in a back page someplace in The New York Times. But as an infectious diseases person, we also have our own 00:29:00feeds, and we get these reports. It was certainly something I was following, just kind of peripherally. At this point, I wasn't studying viruses, I was doing malaria. Ironically, I was the head of virology two months prior, studying diseases like dengue hemorrhagic fever, which is a hemorrhagic fever virus, just two or three months ago. But I was a malaria guy, so this was just kind of an interesting, if not sad, incident that was going on in Guinea in early March.

I got on the plane, I think it was March 25th of 2014, and it may have been even the day before, there was a rumor of a case in Liberia, and the case was in Lofa County. Lofa County is right over the border from Gueckedou and Macenta, which is where the first cases in Guinea were, and these cases were in early March. Now this is March 24th or 25th, I'm getting on this plane, maybe there's a case in Liberia, really not confirmed. It takes about thirty-six hours to get to 00:30:00Liberia from the US, and on that trip we stop off in Accra, Ghana, and that's like a refueling stop and we take on some more passengers from other planes. I think we're there for two or three hours, and at that point, over the time that had elapsed since I left from Atlanta, the reports, the drumbeats were getting louder that this case in Liberia was actually the real deal. Somehow, the pilot heard this, and the pilot was very concerned about this. This is on the layover in Ghana. The pilot is talking this over with the flight attendants. One of the flight attendants happened to know that I was an infectious diseases doctor because I was reading through journal articles, and she talked with me a little bit. Apparently, when the flight attendant and the pilot started talking during this layover, she's like hey, I've got this guy from the CDC who is an 00:31:00infectious diseases doctor. So I'm minding my own business on the plane, on the tarmac, and all of a sudden, I get paged to go up to the cockpit. Never been to a cockpit before. I have no idea why they're calling me. I walk up and I see the pilot, and the pilot invites me, it's just the two of us in the cockpit, and he looks at me and he's like, "You've heard about this Ebola." I said "Yeah, kind of," and then he filled me in on what had happened over the last twelve to sixteen hours, which really wasn't much more of a development than what I already knew. He said, "You know, I don't need to go to Liberia. If you tell me, I'll just turn this plane around right now." I'm saying whoa, this guy is really taking this seriously. So I go through what I know about Ebola, and at that point, this is prior to all that we know about now. But what he's telling me and what I knew, there is one possible case in very rural Liberia. All of these 00:32:00people on this plane are going to Liberia, they're going to Monrovia. I'm going for a very important malaria meeting. I didn't really see much of a threat. I didn't actually see much of a possibility that this was going to get out of control. I still viewed this as a very regional, a very local outbreak. So I said no, no, no, I think you're overreacting to this. He pushed me a little bit, I pushed back a little bit, and within an hour, we're up in the air flying to Monrovia.

Q: Wow. That's remarkable.

HALSEY: Yes.

Q: Can I ask, do you know where the pilot was from, like his nationality?

HALSEY: He was US. Yes. This was a US carrier. I'd hate to think how he would react when there were a thousand cases in all of these countries, which is where they were six to eight months later.

Q: At this point, as you're flying in and you have this awareness about a little 00:33:00case, you don't--you're not thinking that this is going--that Ebola is going to be much of--going to take much of your time, right? That your focus is still going to be on the meeting, on malaria. Or what do you--

HALSEY: Yes. When he told me that, yes, that's what I was still thinking. Then I land about two or three hours later, and I'm met at the airport by Christie Reed, the only CDC person in the country permanently. She's also a physician, and she looked at me and she's like, "Your visit has just changed."

Q: Oh my God.

HALSEY: I was informed when I was picked up at the airport, I think this was March 26th. And instead of going to where I thought we were going to go--to do a little site visit to check out a treatment center, a malaria treatment hospital center, maybe fifty to sixty kilometers outside of town--we went to the Ministry of Health [and Social Welfare] where I met the minister of health. Not something 00:34:00I was expecting to do straight out of the plane, and in fact, after I left that meeting with the minister of health and just about six or eight other people in that office, I hear him on the radio talking about Ebola, as I'm in the truck leaving his office. It became more clear to me that this trip may be more than just about malaria.

Q: Am I right in thinking that was Minister [Walter T.] Gwenigale?

HALSEY: It was Gwenigale, yes.

Q: Can you tell me more about that meeting? What was his demeanor, and what kind of questions were going around?

HALSEY: Nothing really stands out. He didn't seem particularly inappropriate or anything. This was a very extraordinary time, and I think he was dealing with it like anybody else would at the time, trying to get all the facts, trying to figure out the best way to handle this. He wanted us to make sure that the CDC knew about this and that they were in the loop. The CDC already knew about what 00:35:00was going on in Guinea, and obviously, they were also somewhat aware that maybe there was a case in Liberia. So shortly after that, Christie and I are on the phone to the [Viral] Special Pathogens Unit in Atlanta, telling them what we know and what we need.

Q: Who were you corresponding with at Special Pathogens?

HALSEY: It was Pierre Rollin, as well as Barb [Barbara] Knust, I think is her name.

Q: Yeah, Barbara Knust.

HALSEY: Knust, okay. Yes.

Q: Hard K. [laughs]

HALSEY: So quite a few calls, and I remember--I think Barb was even pregnant at the time, and there may have been another pregnant person in the Special Pathogens Unit, and I don't think they really had a lot of people to donate at that point. Guinea was already having big issues, and so initially they were a little bit resistant. They certainly wanted to help, but this is a very small group of people. They counselled Christie and I on the best ways to talk with the minister and his folks and shared with us some information that we can pass 00:36:00along. But as this transpired over the next three or four days, it became more and more clear that this is not something that Christie and I could manage alone, especially as we're juggling malaria issues. Keep in mind, malaria kills thousands of people every year in West Africa. It kills about two thousand people every year in Liberia, probably nine to ten [thousand] in Guinea, probably about that many in Sierra Leone. When you think about that compared to Ebola, even in one year, malaria may have killed more people than Ebola even in one of its worst years. Christie and I certainly did not want to take our eyes off of malaria, and this became harder and harder to do over the course of the week. In fact, it became harder and harder to do over the course of the year or the two years that this epidemic really raged.

Q: What was making it clear that this is not something that you two can handle on your own?

HALSEY: Good question. Initially, it was just one case, it was unconfirmed when 00:37:00I left the US. It became confirmed maybe on March 29th, March 30th. Now I'm in Liberia for maybe two days, so that was certainly a huge announcement. But during my two weeks there, we had the first case in Lofa, but then we had other cases too. We had that one case, and then I think there was at least another case in Lofa of somebody who got into a taxi, and they got into a taxi, and I think they wanted to go to Monrovia. On that trip to Monrovia, they threw up, and threw up, and there were other people in the taxi because this is how these taxis work, they cram as many people as possible into these things. As far as I remember, this person may have made it all the way to Monrovia and dropped off at a hospital. But then the taxi cab driver ended up cleaning out his taxi with all this vomit in it; I think he had his family members clean it out; there were other people in the taxi on the ride. So a certain percentage of those people ended up getting sick. I went from having one not-confirmed case when I landed 00:38:00to a handful of cases by the time I had left, somewhere between five and fifteen. Every day, I would read the papers and it would blossom a little bit more every single day, and you could tell that the tension was just ratcheting up day by day. Dr. Gwenigale's life was becoming more difficult and more difficult day after day.

Q: Does that mean that you were getting more and more calls from the minister?

HALSEY: To be perfectly fair, he wasn't completely dependent on us--he had lots of streams of information--

Q: Of course.

HALSEY: So we would attend his daily briefings, but eventually, we talked to Special Pathogens and the CDC headquarters enough where they sent out other people who could dedicate one hundred percent of their time to this. Those folks were there probably in late March or early April, so probably within a week of me arriving. Ever since then, there's been a continued presence, first just with 00:39:00those two people that showed up, and then it became more like ten, and then it became dozens and dozens and dozens of people that were there, sometimes for months at a time.

Q: Was it a two-week trip in Liberia, is that what you said?

HALSEY: Yes. My trip was scheduled to be two weeks, and it ended up being two weeks. The first week was very Ebola-centric, although we still had malaria to concentrate on. By that second week, we were back focusing on malaria, although it was [hard to] tune out all the Ebola chatter on the radio and the newspaper, in the hallways, everywhere you went. It was the talk of the town, and the town was very scared.

Q: I'm going to direct listeners, Eric wrote a fascinating piece for, I think it--was it MMWR [Morbidity and Mortality Weekly Report]?

HALSEY: It was The American Journal of Tropical Medicine and Hygiene.

Q: He actually had the foresight to collect these newspaper articles that were 00:40:00reporting on Ebola and really sensationalizing it, and just looking across these things, it's clear that there's--this has been said before, but not just an epidemic of Ebola, but an epidemic of fear that was blossoming. During that first week or two, did some of those articles come from that initial period?

HALSEY: Oh yes.

Q: Did they all come from--

HALSEY: They all came from that. In the capital city of Monrovia, they may have five to ten main newspapers. It's not a very large country to begin with, it's about four million people, but unlike the US, they still have newspapers and they have many that people read. Many of them would come to the hotel where I would stay, and many would go to the [US] Embassy. After everybody had read these, and the hotel manager was going to throw these out, I said, "Just give them to me." Every day, I'd acquire another four or five newspapers. Some were 00:41:00very professional. I've got to be fair, many of them were just reporting the facts. But some weren't, for sure. Some would just ratchet up the fear, even more than you would even ever have imagined, putting in pictures probably cribbed from Hollywood or from some sort of horror book, and just say things that were patently false about Ebola, like it could kill you in seconds or that it could be transmitted by vegetables and all sorts of strange things. This was not just confined to the newspapers--the radio would also disseminate messages. Once again, many of them were very responsible, but I heard something about grains in a market and we can't go to that market, don't go to that market anymore, those grains have been associated with Ebola. It was hard to get out in 00:42:00front of these messages, especially when our Ebola messages weren't really refined at that point. At this point, Ebola may have infected or affected maybe a thousand or a couple thousand people in the world over the last three or four decades. Everything that we'd known about the manifestations, about transmission, was based on these isolated outbreaks throughout the world, oftentimes where we did not have--and "we," I mean any medical professional or epidemiologist, had any sort of foothold. Often, when we'd show up to these outbreaks, it had already been festering or almost completed. A lot of these messages really weren't well used, well known at that point.

Q: Do you remember what the guidance that you got from Special Pathogens was? What some of that messaging was?

HALSEY: In fairness to them, I think they did have a lot of prepared information, probably unlike almost any place in the world. They did pass along 00:43:00some pamphlets that we could post and share with the Ministry of Health. In fact, those were up hanging in hospitals and different centers throughout the city, even before I left, two weeks after I had arrived. We were very dependent on the few places in the world that actually had thought about this and drawn up plans for this circumstance.

Q: Do you remember which of their messages might have been--

HALSEY: So what were some of the main messages?

Q: Some of the main messages in that.

HALSEY: I have a lot of them in my office still. But a lot of it's just about washing your hands, about not eating bats. That was one of the main associations with this, besides some of the ways that humans could pass it along to others. Some of them, I remember, there was like a one-page handout about the main ways of transmitting it and the main ways of protecting yourself. Some had to do with 00:44:00burial practices. But once again, not a lot was known about what is the proper way to bury somebody. A lot of that was actually--a lot of that knowledge was refined over the two or three-year epidemic that was experienced in West Africa.

Q: True. Yeah, unfortunately, there were so many cases that you could actually learn how better to deal with it.

[break]

Q: We had just been talking about the messaging. Can you tell me about the time, about the arrival of the two other CDCers, about a week in, you said, to your time in Liberia?

HALSEY: It was roughly probably six to eight days after I'd shown up, and probably only four or five days after we called the CDC headquarters initially and said please send somebody. As I said, initially, the CDC pushed back, saying they are already overtaxed, overburdened, they could only send so many people out to West Africa, they already had people concentrating on Guinea. But as things started to ratchet up in Liberia, they found some people. At the CDC, 00:45:00fortunately, we have a huge pool of people who know how to respond to outbreaks, who've worked overseas, who've worked in Africa, who know the drill. This is one area where the CDC really excels over almost any other institution in the world. And we were able to tap into that.

Q: Who--and I know Joel Montgomery was one of the people who came out, who was the second?

HALSEY: Joel Montgomery and [Brett W.] Petersen.

Q: Did you speak with them much?

HALSEY: When they did show up to the country, I spoke with them right away. In fact, their first dinner in the country was with me at the--I think it's called the Mamba Hotel, next to the--

Q: Yes, Mamba Point?

HALSEY: Mamba Point, yes. Yes, I still remember that very well. I was very excited to see somebody else there so I could refocus my energy on why I was there, and so they could concentrate one hundred percent on this outbreak. I 00:46:00know that Joel was there for quite a long time afterwards, and as you know, dozens and dozens of people followed after he was there.

Q: What did you think of the trip from a malaria standpoint? Were you able to do everything that you wanted to do regarding the meeting?

HALSEY: Ah, no. Often on these trips we'll go out to the hospitals, we'll go out to the field and do a site visit in a city other than the capital city, but all that got kiboshed by the embassy, and for good reason, you could see why. It really changed the focus of our trip. We were still able to achieve what we needed to achieve and meet with the people we wanted to meet--we just didn't have the experiences that we often do on these trips, to get out to the field. This became more of a restricted visit. We're in the halls of the embassy, maybe in the Ministry of Health, so now not talking with the minister about Ebola, but 00:47:00talking to some of his other folks about malaria, occasionally ducking our head into the Ebola meeting just to see how things are going.

Q: Is there anything else left to say about those couple of weeks in Liberia that we haven't talked about?

HALSEY: I think we've touched on most everything I can remember.

Q: What happens then?

HALSEY: What happens then? I come back to the CDC. I'm a full-time malaria person, but as I said, I'm working in West Africa, so seven of my countries--the seven places that I'm concentrating on, many of them are either now already experiencing disease or maybe grappling with their first case. Senegal was another place where I was working, and they ended up having a handful of cases. Nigeria was another place where I was working--they had a handful of cases. I remember that both of those countries actually responded very well to these outbreaks. I was working in Guinea and Liberia, who unfortunately, just were overwhelmed by this. My concentration was still malaria, but Ebola impacted 00:48:00everything in these countries, including how to treat malaria and how to diagnose malaria, and really set public health measures back a bit when it comes to malaria in all of those countries, but especially Guinea and Liberia.

Q: Can we dive into that?

HALSEY: Sure, sure. One of the main ways that it affected malaria--just to back up, the correct way to manage malaria, and something that we try to indoctrinate in all new malaria doctors, is that you need to diagnose it first, before you treat it, which sounds very, very straightforward. But for many years, what people would do, doctors would just see somebody who would come into their hospital and say, "That person has a fever, malaria causes fever in almost everyone, I'm not going to diagnose. I'm a doctor, I've been doing this for thirty years, I'm just going to treat." Usually, they'd be right, but not always. If you're assuming something is malaria, but it turns out to be 00:49:00something else that's fatal, then somebody could end up dying. But also, you could be giving drugs to somebody who doesn't need drugs and you could also be fostering resistance. There's all sorts of reasons why we wanted this message to get out--you've got to test before you treat. This was the pretext to, then Ebola comes along, and then to test you've got to take a prick of blood from somebody's finger and put it on a rapid diagnostic test. But now, if somebody is coming to your health center and they have a fever, they could have Ebola. So are you actually going to expose yourself to their body fluids? After spending the last three to five years getting these training messages out throughout Africa, then we had to kind of reverse course and say, "Now that you all are testing before treating, let's not do that anymore." That was the scenario some 00:50:00places where we were, and it was a very difficult message to get out there, even made more challenging by there were supply chain issues. It was hard to get insecticide-treated nets to where they needed to go, it was hard to get anti-malarials where they needed to go. Places that could still use rapid diagnostic tests, that was also hampered because a lot of this--so, people were dying, but also a lot of the resources were being redirected or people didn't want to go to work, they didn't want to put themselves up to the risk, which is really hard to fault them for. We had to deal with that too. And all these very routine measures that we used to take for granted became very challenging, including mass distributions of insecticide-treated nets, for example. It just took on a whole new level of complexity in these countries.

Q: Did you actually have direct conversations with doctors who were resistant now to want to treat patients for malaria symptoms?

HALSEY: So, did I have conversations with the docs?

Q: Yeah, yeah, sorry. I'm not phrasing things very well today.

HALSEY: No, no. I mean, we've run into resistance with whichever thing that we're trying to promulgate. Initially, it was really hard to get doctors to adhere to the test-before-treat motif.

Q: Right, and so your message was you need to test--

HALSEY: Right.

Q: And then testing becomes problematic.

HALSEY: Right. For a while, we were then kind of un-educating these people into what we were educating them before. But now, here in 2018, we're now saying it's time to go back--in fact, we said that long before 2018. It's time to go back to the test-before-treat motif. It just sets everything back just a little bit when you throw that complication, that new twist, into everything. The hardest health care workers to educate, because we educate community health workers who barely 00:52:00have an advanced--they barely even have a high school education. We educate nurses, midwives and doctors; the hardest people to educate are the doctors. They are the ones that are most sure that they can diagnose somebody without a rapid diagnostic test. They're always the most challenging, those doctors.

Q: That's super interesting. I don't know if you have been able to produce numbers that show some of the impact that Ebola has had on malaria over the last several years.

HALSEY: There certainly have been studies about that, and there's a big one out of Guinea that I was actually part of, that showed that, indeed, there was an impact of Ebola on malaria care.

Q: Dr. Mateusz Plucins--

HALSEY: Plucinski, exactly.

Q: He's talked about--

HALSEY: Yes, he was the lead author on that and that ended up being published, I think, in the Lancet Infectious Diseases journal.

Q: That's all super fascinating, and I'm happy to get that part of the record for our oral history project. You also mentioned to me that you spent six weeks working on STRIVE, Sierra Leone Trial to Introduce a Vaccine Against Ebola. Is that correct?

HALSEY: That is correct. That started in January 2015. I was there for six weeks, this is Sierra Leone. I was based out of Freetown, but also worked in Bombali and Tonkolili [Districts], and this was just setting the groundwork for the vaccine that they would later introduce in a trial. It was a very interesting time. On our team, at any one time, we had about twenty-five or thirty people, so it was a large contingent of us all holed up in our headquarters in Freetown. Most of my time was spent on focusing on the vaccine and writing standard operating procedures: what would happen if somebody came to the vaccine trial and they were bleeding, or if they fainted when they got the 00:54:00vaccine, or if they died after they got the vaccine. Thinking about all these things from a medical standpoint, that was my particular niche on the team. In addition to that, many of us on the team would also do routine Ebola runs with all the other epidemiologists who were there for the actual response. That was fascinating and very eye-opening as well, and that would take me to the hospitals as well as out to the rural areas to see how Ebola was being treated and where the gaps were in that.

Q: Are there specific ones of those Ebola runs that stand out to you when you look back?

HALSEY: Yes, for sure. I actually have some good video I could share with you on some of these, but really, the thing that stands out the most are visiting these villages that were quarantined. When somebody in a household was diagnosed with Ebola, that meant for everybody else in that household--and these aren't normal 00:55:00households that we would think of in the United States. For one, there are many more people: often a household would have ten people or twelve people in it. And they were often much smaller than what you would think of as a household in the United States, much, much smaller, maybe as big as a hotel room, and obviously, not with the normal lighting and sanitation. If somebody got diagnosed with Ebola in that household, everybody in that household would have to be quarantined anywhere from a few days up until three weeks. That means that they're followed; if they have a fever, then they even have to go into more--like a different type of quarantine called "isolation." But even if they are just quarantined, they can't go out and work, they can't even go out and get water or food. So we'd visit oftentimes many of these quarantined areas, and one thing that--many things struck me about these visits, but the first thing that struck me is the way that they would wall off these houses. Everything that I 00:56:00knew about Ebola, that I had seen in the popular press or even just in movies, I think of The Hot Zone or Contagion where they put up the big biohazard hazmat around the house. Not the case in these quarantines. It was twine. They would pretty much just string up twine, maybe six to eight feet outside these houses or huts, just around poles that surrounded it, and you could walk up to these people who were in this family that had a family [member] who died, and they'd be on one side of the twine, and you'd be on the other side of the twine. Like the twine is going to somehow prevent the Ebola from crossing over to you. It just always struck me as very, very odd. It was almost always twine. Sometimes it would be a very thin rod, demarcating where people can't go in and out.

Another thing that struck me about these quarantined villages or households is 00:57:00that these people couldn't go out for days or weeks. They're completely dependent on other people, oftentimes the World Food Programme or their neighbors or whoever, to bring them all of these necessities. This didn't always work great. I do vividly remember visiting a village, I think it was in the old wharf of Freetown, where they hadn't gotten any food recently, and these people were so, so mad. We were there as epidemiologists making sure everybody was doing okay, doing contact tracing, and they were fuming at us. I thought it was going to really escalate, and fortunately it didn't, but I could see--I could completely comprehend how these people who already had people taken out of their households, maybe died, that were in their family, and now they're being starved, prevented from getting water and the basic necessities, and then we're coming by and asking about who's sick. It was some very heated exchanges.

Q: How were you able to respond to that, to that anger?

HALSEY: First of all, I didn't respond. I was always with [Sierra Leoneans], and often it was a village elder or somebody that was fairly senior and knew how to deal with these complex situations. What I did is I tried to back up and let those people negotiate the best that they could.

Q: Makes sense. Was the anger apparent mostly from the raised tone of voice, the shouting? Did you ever feel physically threatened at that--

HALSEY: Nobody ever got hit, at least when I was doing my visits, and I only did a limited number of these things. But you could tell that it could escalate under the wrong circumstances, and I think there were actually reports of these things spinning out of control.

Q: Do you know the [Sierra Leoneans] who you were working with? Do you know what 00:59:00they were saying to respond to some of these concerns? Like how were they trying to diffuse the situation?

HALSEY: They did all that they really could, and in many instances, it wasn't even their bailiwick to provide food and water to these folks. They were there for epidemiological purposes and to count cases and to make sure everybody was doing okay. They used every device they could to try to diffuse the situation, but the one thing that they couldn't do is they didn't have water on them and enough food to feed twenty-two people. So it was difficult.

Q: I'm sure. Was there anything else that you would like to share about your experience with STRIVE?

HALSEY: I think we've pretty much hit it.

Q: Yeah, I think that was--it was good. I had wanted to ask--it seemed, back to the malaria, it seems to me that it could be frustrating to see such a 01:00:00concentrated, massive, resource-intensive effort to counter Ebola when you have a chronic--not chronic, but--

HALSEY: No, it is--

Q: --a disease that yeah, just an endemic disease like malaria, which as you said, is killing a couple thousand people a year in a country like Liberia.

HALSEY: Right.

Q: And see resources taken away from that. Did you ever feel that emotion?

HALSEY: No, but I could appreciate how some people would. Ebola is such a different beast than any other infectious disease that I am aware of, just with its nature, its transmission, how it can kill people, and it's almost this invisible way that it's killing people kind of like the plague did five to six hundred years ago. How it kills health care workers, how it can just rapidly 01:01:00blossom; it's just unparalleled in its fear factor and really, in a lot of ways, in its case fatality rate, there's few infectious diseases that possess that kind of case fatality rate. So I completely get it. In fact, I was shocked, and actually, I was very skeptical that we were going to get out ahead of this. In September of 2014, October, there were some projections that this was going to take off. Others said if we intervene now, maybe we can cut it short. I actually did not think that was going to be possible. By the time we had thousands of cases in West Africa, each one of those--I think the best analogy is embers. Each one was an ember that can fuel another fire. I just didn't see how this would ever burn out. I understand why some people might say, why doesn't malaria get the same attention, but as somebody who concentrates on malaria, I totally understand why Ebola got the attention that it got.

Q: That makes sense. That makes a lot of sense to me. So can you tell me about your work after the STRIVE trial, over the last couple of years? What have you been focusing on?

HALSEY: Back to malaria. I'm still with the President's Malaria Initiative, I celebrated my fourth year anniversary just a couple of weeks ago. Still working on diagnosis and treatment, and really, the main thing that I focus on of many things is making sure that resistance to the main anti-malarials does not come and spread in Africa. The way that we do that is that we set up trials in different--or studies in different countries. One thing that's really gratifying about some of these studies that I'm doing currently is that opposed to all the samples coming to us, here at the CDC, we're trying to now train people in Africa and these countries to actually do the testing themselves. What that 01:03:00entails is bringing people over from Africa. Currently we have somebody from Benin in our laboratory, in our malaria laboratory, working with us for six weeks, learning all of these very intricate procedures, with the plan that they'll do it the next time they do their own study. These studies happen every two years. You've got to do these studies all the time in many different places to make sure resistance isn't popping up. It's really a very gratifying part of all of this work, and this work is very scary. To think about antimalarial resistance coming back to Africa, it's something that the world had to grapple with many decades ago, and it sidelined any sort of hopes of malaria eradication or elimination back many decades ago. The fear is that it's going to come back, and we're seeing this resistance right now in Southeast Asia, which has about one twentieth of the number of cases that Africa does. But if it makes the jump to Africa, it could really, really be a challenge.

Q: That does sound completely terrifying.

HALSEY: It is terrifying.

Q: Wow. Good luck with that work. Dr. Halsey, was there anything that we didn't get to talk about, any memories or final reflections you wanted to give before we end the interview?

HALSEY: I think we've tapped my memory completely. I'm all out. [laughter]

Q: Well, I've wanted to get you in here for a long time and I'm really pleased that we finally did.

HALSEY: Thank you, Sam.

Q: Thank you so much for being here.

HALSEY: Okay.

Q: Awesome. [laughs]

HALSEY: Hopefully I gave you what you needed.

Q: Yes. That was awesome.

HALSEY: That's all that I remember.

Q: Was Christie Reed also with you throughout that trip?

HALSEY: Oh yeah. In fact, Christie was a very central figure in Liberia. First, just being the only CDC person there, the only permanent person there. She was brought into almost everything Ebola. I said that I got pulled out of it after five or six days once Petersen and Montgomery showed up. But Christie, she was 01:05:00tapped on a daily basis.

Q: Is she still over there?

HALSEY: She left about a year ago. She's now in Kenya, working in GID, the Global Immunization Division. I think she's still in GID.

END