Dr. James Lange

Dr. James V. Lange

Q: This is Sam Robson here today with Dr. Jim Lange. Today's date is May 30th, 2017, and we are in the audio recording studio at the CDC Roybal Campus in Atlanta, Georgia. I'm interviewing Dr. Lange as part of the CDC Ebola Response Oral History Project. This interview follows one that Dr. Lange did with Dr. Paul [M.] Fiorino with StoryCorps several months ago now, which I do plan to have transcribed and added to our online archive Global Health Chronicles so that people listening to this can access that one as well. I highly recommend it. Dr. Lange, thank you so much for being here with me.

LANGE: My pleasure.

Q: For the record, would you mind stating your full name?

LANGE: Yeah, my full name is James Valmas--it's a Greek name, V-A-L-M-A-S--and my surname is a German surname that because of my origin in South Louisiana got bastardized into a French pronunciation of Lange. The only other place that I've 00:01:00been called Lange spontaneously is in France.

Q: Interesting. Can you tell me what your current employment status is, retired but still--

LANGE: Yeah, I'm retired.

Q: --not really retired.

LANGE: No, no, I'm retired. I'm doing some writing, but I'm doing nothing that could be directly tied to my previous work here.

Q: Sure. But still doing--

LANGE: I still follow literature, still get alerts from a couple of journals.

Q: Right on. Thank you. If you were to give a short, capsule description of your work as part of the West African Ebola response, what would you say in just a few sentences?

LANGE: I'd say in 2014, I started out working in the field of risk communications because I was working in an emergency preparedness and response 00:02:00capacity within the Division of Preparedness and Emerging Infections, DPEI, and was deployed to West Africa as an assignee for health risk communications. But upon arrival, I was pulled aside by the country director, Dr. Kevin [M.] De Cock, who [earlier] became the [first] Center for Global Health director, who started his career where I was working at the time, in Viral Special Pathogens, so we had a connection that went back into the early eighties. He asked if I would consider going to the field to support an epidemiology team in Bong County. And after a little bit of discussion, I said yeah, I'll be happy to do it as long as you feel that someone with no epidemiology experience, such as myself, could play a meaningful role and truly support what was needed. He said 00:03:00yeah, just do what the other epi [epidemiology] people tell you to do. And that's what I did. It worked out okay.

Q: That's awesome. And so that was in 2014.

LANGE: Yeah, that was in November-December of 2014. And fortunately, three days after I was posted to the so-called county seat called Gbarnga in Bong County at the hotel that we both stayed in--

Q: The Passion Hotel?

LANGE: The Passion Hotel, outside Gbarnga, I met up with the official epidemiology assignee, Dr. Patrick [K.] Moonan from the [Global] Tuberculosis Prevention [and Control] Branch. He works on the campus right off of Buford Highway.

Q: Oh, Century--no.

LANGE: It's not Century either, it's Corporate Square. Yeah, he's at Corporate 00:04:00Square. Very nice gentleman. We worked with the other epi folks and did some troubleshooting on tracking what then were pop-up cases, tried to assist and facilitate the system that had been set up. Throughout West Africa, actually, the World Health Organization and all of our other international partners did some fantastic work there. They put together the logistics for training community health workers, for getting people issued phones so that they could go to these remote villages and call a predesignated emergency number and communicate with one another. And set up essentially an emergency notification system in case there were some pop-up Ebola queries so that they could one, get 00:05:00people to be picked up by ambulances if they were available--that was the other really neat thing that WHO [World Health Organization] played a significant role in, setting up contracts with ambulance drivers, ambulance companies and with the county health departments. And it all, by the time I arrived, seemed to be operating--not necessarily in a super-efficient manner, but in a functional way that was one, identifying new cases, getting them to Ebola treatment centers or ETUs as they were called, Ebola treatment units, that had already been set up. And the one in Bong was set up by the International Medical Corps at a former leper colony site in an area called Suakoko. When I first saw it, I said "Sue-a-koko," and they said no, it's "Swakoko," even though it's spelled 00:06:00S-U-A-K-O-K-O, right across from that university where all of the IMC staff stayed. Things were functioning, things were working. They were getting people into the triage, identifying true Ebola cases, getting them into the treatment wards, saving lives as best they could. They had reduced the death rates already from way over fifty percent down to the low forty percentiles, and the dedication and the determination of those people just overwhelmed me.

Q: I hate to do this, but do you mind if I rewind us a little bit?

LANGE: No, please.

Q: I'm putting a little note so that we make sure that we get back to that.

LANGE: It inspired me.

Q: So you worked there for a couple of months and then you had maybe four--

LANGE: Yeah, Dr. Moonan, with Dr. Moonan.

Q: With Dr. Moonan. And then you returned, but to Sierra Leone, for maybe four 00:07:00trips or so as part of STRIVE [Sierra Leone Trial to Introduce a Vaccine against Ebola]?

LANGE: Yeah, five trips total.

Q: Five trips.

LANGE: I returned from the epi experience in Liberia and then was asked if I would be willing to go manage an immunology laboratory in Freetown, Sierra Leone, as part of the Ebola vaccine project. I initially deployed for forty-five days, I believe, and took over from a young lady named Stephanie Sincock who [is with BARDA, the Biomedical Advanced Research and Development Authority, and] had set up the laboratory, trained the laboratory personnel, and did truly wonderful work. She was out of the Office of the Secretary in Washington [DC], and I'm blanking on the name of her, but I'll [see] if I come up with it.

Q: That's good. We'll get back to the STRIVE experiences as well.

LANGE: What I had to do there was make sure that we had, first of all, physical set-up to operate safely, which I was able to facilitate somewhat to make sure our laboratory workforce was adhering to the basic principles of biosafety while they were doing it. And then to help them with the whole process of going through identification of candidates, the Ebola vaccine trial, which was called STRIVE--

Q: Sierra Leone Trial to Introduce--

LANGE: Sierra Leone Trial to [Introduce] a Vaccine against Ebola, S-T-R-I-V-E. It was limited to healthcare workforce people, exclusively, but that was broadly defined--anyone who worked in a healthcare facility, in any capacity, including 00:09:00the janitor, who in reality would be exposed to patients, was eligible. I had nothing to do with the recruitment, but at least I familiarized myself with that process. A subgroup from the group that agreed to get the vaccine also agreed to donate blood to see whether or not the vaccine was stimulating their immune systems properly. We started that, and the goal when I got there was to have two hundred serum collections at multiple times over the period of the study. While there in that first period of forty-five-days, the numbers that we were to collect kept changing, and so it went from two hundred to three hundred to four hundred to five hundred, then back to four hundred, as being statistically 00:10:00powerful enough to be able to give them sufficient information to be able to make statements about whether or not the immune response as we anticipated them to be--they were going to be measuring antibody responses, humoral antibody only--if those responses were adequate. It could form the basis of explaining why the vaccine might be effective. Of course, the idea, all the while, was in case there were any new outbreaks, that the vaccine would be deployed in order to prevent the spread of Ebola. We'll see later on that, in fact, did happen, and the World Health Organization declared that this particular Ebola vaccine, which is a vesicular stomatitis virus, a VSV construct, that uses a virus that's 00:11:00important in agriculture that infects udders of cows--VSV virus, it usually doesn't infect humans--is used as a vehicle for transporting an antigen from the Ebola virus. Genetic engineers can take a piece of the Ebola coat, so to speak, and attach it to this VSV, which doesn't grow the way viruses normally do, it hangs out for just a short while, but presents that antigen long enough for people's immune responses to recognize it and respond to it.

Q: That's so cool. One very quick question, and then I'm going to have to reset the computer back here because something went awry. Is that virus, what was it, the stomatitis--

LANGE: VSV.

Q: VSV.

LANGE: Vesicular stomatitis.

Q: Is it at all related to cowpox?

LANGE: No, cowpox is a completely different virus.

Q: Okay, gotcha. When I think of a disease that's related to cow udders, I think--

LANGE: Yeah, coxpox is actually a disease that led to the discovery of the agent that was used to eliminate smallpox, it's called vaccinia virus. It's a cousin of smallpox that produces a disease that looks somewhat like smallpox, but usually is not fatal, although it can be because vaccinia is a pretty nasty virus in and of itself. But it was used for many, many hundreds of years to prevent smallpox. And the reason that it came to be recognized as such was that there was a British ambassador, I believe in Turkey, who recognized that milkmaids picked up cowpox from cows and somehow none of those girls ever got 00:13:00smallpox. There was some interesting work that followed that where I think family members were inoculated with the pus from a vaccinia sore and people got sick, recovered, but were immune, in fact, from smallpox.

Q: Public health, gross but often effective.

LANGE: So that's how smallpox vaccine got started. But understand this, that even during the height of vaccinia virus's use as a vaccine against smallpox, there were some very serious side effects from its use in a small, extremely small group of maybe three to five people per million doses given. Today the only US citizens, who get smallpox vaccine, which is vaccinia virus, are military personnel. They still must get it because of the potential of using 00:14:00smallpox as a bioweapon.

Q: Right, makes sense. Okay, I'm going to flip this thing back here.

[break]

Q: Okay, we're back after a fifteen-second break, sorry about that--resetting the computer. Jim, can I ask you where and when you were born?

LANGE: Yeah, I was born in New Orleans, Louisiana, September of 1946, a year after the war. My dad had served in the merchant marine service [United States Maritime Service] ferrying bananas between the Port of New Orleans and South America. And then was diagnosed with type 1 diabetes and was mustered out of the Merchant Marines, met my mom, and they were married in May of 1945, and I was born in September of 1946. I was the only issue from that marriage.

Q: What did your mom do?

LANGE: My mom actually was one of the original prototypes for working mothers. 00:15:00Even in preschool years, she worked. I can remember going to an aftercare facility as a Kindergartner to let my mom do work as a stenographer for a group of lawyers, which she did for a few years.

Q: Was it always as a stenographer when she was working?

LANGE: Yeah, yeah, she strictly provided stenographic and typing, she was an expert typist on the old mechanical typewriters. She did excellent work, and she was very smart because she not only worked, but she saved, and after my father's death, she did very, very well for herself.

Q: Then your dad, so he transitioned from the Merchant Marines to something else.

LANGE: Yeah, he did, he went to work for a company called Friden Calculating Company. It was not a Frieden with an E, it was a Friden with just an I, and I never found out the derivation of it. But the company was headquartered in San Leandro, California. The only place I've ever seen a Friden calculator prominently displayed is in the movie The Apartment, which Shirley MacLaine won an Academy Award for in the 1950s. In one scene where Fred [Frederick M.] MacMurray, the evildoer in the storyline, works, he supervisors a whole floor of nothing but desks with Friden calculators sitting on top of them, and you can hear them going through their gyrations, making calculations. They were the fanciest high-tech computer-like computational device that existed in the fifties.

Q: Can you remind me where you grew up?

LANGE: Yeah, I grew up--actually, I was born in New Orleans, moved to Baton Rouge because Friden transferred my dad there when I was two. Then I moved back to New Orleans at age twelve. So I spent my adolescence in Baton Rouge, went to Catholic grade school, and then moved back to New Orleans and went to high school in New Orleans, again at an all-male Catholic school.

Q: What was it like going to the Catholic schools?

LANGE: Oh, I didn't know anything else. It was a significant influence on me because we never questioned who was in charge and we did get what I felt was very good preparation for college. It was never a question about whether or not we were going to do what we were told, and as long as we did that, we were 00:18:00laying good foundations for having successful college careers and graduating college.

Q: Can you describe a little bit about your [time] in New Orleans back when you were in high school?

LANGE: I did not live in the city itself. I grew up in an area that's now called River Ridge, in what I think is a near-idyllic condition--that was a fairly new subdivision with nice homes in a nice community, swimming and tennis facility that everyone seemed to belong to, and just crawling with baby boomer types like myself. We all enjoyed spending time with one another, being on the same swim team with one another, competing against one another on tennis courts, and every single peer that I had, that I grew up with, attended college, graduated, and 00:19:00either became a professional--we have one who is a child psychiatrist, one who is a physicist, one who is the chairman of the board of--what's it called--the health food company.

Q: [laughs] Paul Newman's health food?

LANGE: No, no, no, not Paul Newman, the big--

Q: Health foods?

LANGE: Yeah, health food, but what's the name of the company? I'm blanking on it.

Q: Is it Whole Foods?

LANGE: Whole Foods, yeah. He is the chairman of the board of Whole Foods and a retired professor at Tulane University.

Q: And you're still in touch?

LANGE: Oh yeah, all the time. We're still close.

Q: Wow. So did you have an academic interest when you were growing up?

LANGE: From the time I was a kid, when people asked me what I wanted to be, I said I wanted to be a scientist.

Q: Yeah?

LANGE: So I took science. I took all the science I could in high school. I 00:20:00didn't know exactly which science I wanted to study in college, so I took a few. Chemistry didn't really motivate me, the zoology was okay, but when I took my first microbiology course, it really piqued my interest. And then when I took immunology, it exploded. I decided to be a microbiology major and got a microbiology degree in 1969.

Q: Where were you attending?

LANGE: LSU [Louisiana State University] in Baton Rouge. I went back to Baton Rouge for college. Then, because of the timing of my graduation, I lost what was called my 2-S deferment--people in four-year and some even in graduate schools and professional schools received a Selective Service classification of 2-S automatically, until they completed that curriculum, with time limits of course. 00:21:00They wouldn't give you eight years to get your bachelor's degree. They'd give you four, and then if you didn't complete it in four, they would change your classification from 2-S to whatever your induction physical said that you were classified as, which in most cases was 1-A, which meant you were prime beef for being drafted. I went through that process, went into the [US] Army in March of '69. I went through basic training at Fort Polk, advanced training at Fort Leonard Wood, and then while there, took an option to go to Officer Candidate School because Vietnam was raging at the time. I didn't want to go to Vietnam, so I figured I'd take a six-month stab at becoming an officer, and maybe the Vietnam War might be over by then, who knew. So I went through Officer Candidate School from July of '69 to January of '70, commissioned as an infantry officer 00:22:00at Fort Benning. Got married between infantry Officer Candidate School and my second eight weeks of advanced individual training at Fort Leonard Wood, and so my wife joined me there. We spent nine nice months, I taught at the US Army Infantry School at Fort Benning, and got my orders for Vietnam. Went to Vietnam, did my tour there, half as a platoon leader in a rifle company, which was not very pleasant, and then the last five months, five and a half months as a logistics and civil affairs officer. Before I left Vietnam, I had applied for an early release from active duty to attend graduate school to get my master's in microbiology, was turned down for that, and less than thirty days later, I received a letter saying I was being kicked out of the Army because they had too 00:23:00many first lieutenants. Typical of the military, the right hand never knew what the left hand was doing and vice versa. So I came back to the [United] States, worked for a couple of months, and went back to grad [graduate] school. I got my master's in micro [microbiology] and then came to work here.

Q: Was that again at LSU?

LANGE: Yeah, at LSU, but I did my master's in immunology.

Q: Can you tell me a bit about what you were specifically interested in, in micro?

LANGE: Yeah, my chief interest was the immune response and its complexity in trying to understand even little bits of it, which I'm not laying any claim to doing, but at least when I came here, I knew what it was, how it was measured in the laboratory, and then I was also fortunate enough to have grown viruses, grown tissue culture, and so I was well prepared for the job that I was hired to 00:24:00do here. I felt that I didn't really have to learn much in addition to what I'd brought with me, but all new employees had to go through a number of different training programs and courses that were very good, but still didn't necessarily add to my abilities or preparation for what was needed to do my work. I was a technician in the--well, it started out in the Viral Pathology Branch under Fred [Frederick A.] Murphy, and then after Karl [M.] Johnson and Patricia [A.] Webb came up from the Middle America Research Unit in Panama, I worked for them in Viral Special Pathogens [Branch], which is still the name of the organization to this day.

Q: Do I have it right, that you started at CDC in '74?

LANGE: Yes, July of '74. I was hired by two guys--actually, they were the chief 00:25:00interviewers. The first one was Walter Dowdle, virology division director, and the second was Roy Murphy. Not Roy Murphy, where did I come up with Roy Murphy? Fred Murphy did not interview me at that time, but Roy [W.] Chamberlain did. He was the deputy director--CDC back then had two major groupings: the Bureau of Laboratories and the Bureau of Epidemiology, and that was it. That was the whole kit and caboodle. Of course, it grew from there, and I was hired after interviewing with Walt Dowdle and Roy Chamberlain.

Q: A couple of questions--

LANGE: And by the way, as it turns out, I was hired during a hiring freeze. A [Richard M.] Nixon-declared hiring freeze.

Q: How did that work?

LANGE: For every hiring freeze, there are exceptions. They wrote a justification, which they sent up to Washington, that got approval for this high-containment laboratory technical support. So it had a high enough priority in their way of classifying jobs that they were allowed to hire me during a hiring freeze.

Q: What did it mean to be a technician?

LANGE: It means that you listen to what the boss has to say about what's planned long-term, mid-term and short-term. You're given a fair amount of freedom in what you plan to do on a day-to-day basis. You're given a task, "test this whole rack of sera for this virus or these viruses," whether or not you can grow the viruses or whether or not you're looking for antibodies in some other type of body fluid, and that's what you do. And you plan it that way, and then you bring 00:27:00your results to your boss and talk about them.

Q: Reflecting, again, I want to direct any listeners of this to Jim's interview with Paul Fiorino, a StoryCorps interview that hopefully will be also go on Global Health Chronicles. I appreciated you talking about 1976 in that one, and Yambuku, and the discovery of Ebola, the kind of team discovery that you guys--

LANGE: Yeah, it was, it was, it was a team effort, but it was headed by my branch chief Karl Johnson because of his extensive experience with viral hemorrhagic fever field studies in South America. He was the head of a research unit down in Panama called the Middle America Research Unit in Panama City. That was a big-time operation for that part of the world that was funded by NIH 00:28:00[National Institutes of Health], specifically NIAID [National Institute of Allergy and Infectious Diseases]. He and Patricia Webb, who is a very well-known virologist in her own right--both of those two are physicians, by the way, so they both know all of the medical stuff, and they became experts in the field epi as well as the laboratory parts of it. They are both very bright, very hard working, and for those of us at my technical level, they were fun to work for because they had more ideas and more stuff that they wanted to get done than we could ever possibly do. But that was still very stimulating.

Q: I appreciated how you talked about--how you guys realize, this is not just Marburg, this is a new thing--

LANGE: Yeah, but that was after doing quite a few things in the laboratory itself. We got these racks of blood that Dr. Peter Piot, a Belgian physician who 00:29:00was working in their [Institute of] Tropical Medicine at the time, he did all of the post-mortem and the pre-mortem blood collections, organ samples. He did really the most dangerous work that you could possibly do in an outbreak like that. I don't know who sorted and sent all of the materials, but I knew at the time that we were getting samples that our counterparts in Britain were getting, our counterparts in France were getting, and our counterparts in Belgium were getting. All four groups that comprised the international team there in Yambuku received diagnostic specimens to say, what's going on here? Patricia and I looked at some, we tried to pick some that didn't have a lot of bacterial or mold growth in them because they were all really nasty looking. As it turned out, we didn't know it at the time, but it's hard not to grow Ebola virus--it 00:30:00will grow like crazy in almost any mammalian [cell culture]. We put it into African green monkey kidney cells. The inoculum was fairly toxic--sometimes you can kill the cells you're trying to grow a virus in if the sample is too toxic for it, such as hemolyzed blood. I was able to nurse them along for twenty-four hours, as they looked okay; but not at forty-eight hours. All of those cells told me they were sick when I looked at them under the microscope--it's called cytopathic effect, in our terminology. Based on the cytopathic effect I saw in those African green monkey kidney cells, I said a virus is growing in here. So we waited for another twenty-four hours, I made the harvests, we did all the proper preparations to save back and to look at multiple times if we needed to, put some in the ultra-low-temperature freezer, and then I did an immunologic test on one of the things. That immunologic test said that it was not what the 00:31:00electron microscopy said it was. Part of the process I did was I did electron microscopy preparation, fixative, paraformaldehyde, handed it to Fred Murphy through our safety system, everything was done in a proper, safe way. But Fred, because of the nature of the bug, was the only person to work in the electron microscopy suite that day, and thirty minutes after I handed it to him, he came back and said, "It's loaded with Marburg." That's when I went to the freezer, because I knew where the stuff was. I took out our Marburg reference antisera, did the immunologic test for Marburg on a preparation of those Vero cells as they are called in commonality, infected with what we thought was Marburg. That was negative using an anti-Marburg antiserum. Patricia and I looked at one 00:32:00another, thought we had made a mistake, we repeated it, negative again. So that was the first hint.

Q: One thing that really struck me was--and you're describing how all of these samples went out to different partners--

LANGE: And they all grew the virus, by the way. Talking to them years afterward, they all grew virus, but only one other one, as far as I can tell, did electron microscopy.

Q: Interesting. So Karl Johnson made the decision, once you guys knew that it was new--

LANGE: Yeah, once there was confirmatory evidence that this was a new virus, and that was based on Patricia, specifically, fishing out one of the samples from a patient who survived long enough to make antibodies. A lot of the samples that we had, people were dead by day five once they started showing symptoms. That's not long enough to make antibodies to the virus in all cases. She found one that 00:33:00she squeezed enough antisera out, ran it against the same slide I had made in the original harvest, and that one lit up like a Christmas tree. It showed what we called "immunofluorescence," which is the term used to describe the test--it's called the indirect immunofluorescence test. I was using guinea pig Marburg sera with anti-guinea pig on top of it; she used human serum with anti-human serum with that fluorescein label on it, and that's what lit it up. So that confirmed the fact that this baby looks like Marburg, but it ain't Marburg, it's a new virus. It's a new virus antigenically that is completely different from Marburg. In that short window of time, Patricia and Karl and Fred had all the information they needed to go to press. And they could have done so, 00:34:00they could have sent it in to any of the weekly journals that came out such as The Lancet, which it ultimately got published in, or Science, or any of the other ones that were rapid publishing vehicles. But they diplomatically chose to wait until all of their colleagues had completed all of their work and we could all publish together in one volume of The Lancet.

Q: Can you tell me more about that decision? Because I would imagine that someone like you would be like hey, I'm raring to go, let's get some of this stuff out of there?

LANGE: No, no, no, understand this; I was a technician, so if they said we wait, I never questioned that.

Q: Okay.

LANGE: No, no--

Q: Was there nobody who wanted to get this stuff out there?

LANGE: See, I was only in my second year here. I didn't know anything about how politics played a role, or even if it played a role in science. I've learned 00:35:00since that it plays a big role in it. Not everyone would have done what Karl and Patricia did--they would have gone to press and let their colleagues publish whenever they happened to publish. But being the first is tantamount to being the lead, having the scoop, being numero uno, we got it. They could have done that but chose not to. Looking back on it, it was a very wise thing for them to do because it's difficult to get international collaboration in all instances. We'll see that it worked in West Africa in 2014, '15, '16. Again, not as smoothly as it could have, but it did work. But believe me, there's as much competition between the international scientists as there are between 00:36:00international businessmen, international arbitrageurs, international currency trade, it doesn't matter--they all want to be at the top, they all want to be number one.

Q: So you think that that decision to publish together, I think you said in The Lancet in 1977--

LANGE: Yeah, to wait to publish that, we published it--

Q: --to wait to publish--

LANGE: --in March, the following year.

Q: Right. Months, months after.

LANGE: Yeah. We had the answers in October.

Q: That decision had ramifications for your future working together with these same partners that--

LANGE: Well, only on paper.

Q: --perhaps made it easier to work--yeah?

LANGE: Yeah, there's never a guarantee. But still, looking back on it, it was the right thing and the right decision so that everyone could share the credit. Later on, of course, some of the published and visual media were done by Dr. Peter Piot, who became a world-renowned HIV [human immunodeficiency virus] 00:37:00expert. The media themselves jumped to the conclusion that he was the discoverer of Ebola. I don't recall hearing or reading anything specifically from him that says that "I am the one who discovered Ebola," but he never refuted what the people in the press said either. So by his tacit silence on that issue, he may have given the impression that he is the real discoverer of Ebola. Which is not true, no one can make that claim. No one. We are all parts of the team that discovered Ebola.

Q: Did that tick people off when he tacitly accepted credit?

LANGE: Oh yeah, yeah, yeah, it did. I'm sure it ruffled a lot of feathers in people's bonnets. But again, that's one of those human frailties that you run into that the wrong information gets pushed out into the media and folks start 00:38:00to believe it. If they hear it often enough, everybody thinks it's correct. But it's not. And actually, there was a refutation published last year by a lady, I'm blanking on the name of the article and the lady's name, but her headline was that Peter Piot is not the discoverer of Ebola virus.

Q: Is he living?

LANGE: Oh yeah, yeah. He was a twenty-seven-year old at the time, a twenty-seven-year-old physician. That was the other thing, the whole situation in Zaire was, in 1976--Zaire had been a colony of Belgium for a long, long time. Less than twenty years before, it became independent. This Ebola thing pops up, 00:39:00not knowing it's Ebola. Well, the Belgians felt that they had ownership of it, and understandably. It was their colony, all of the major support personnel and religious personnel who bore the brunt of the early parts of the epidemic were Belgian, Belgian priests, Belgian nuns. The Belgian nuns were the real heroes of the whole effort. The priests got out of Dodge, as was told to me by a close friend named Guido van der Groen. If you go to his website, you can get a real feel for the history of that outbreak. He took some of the earliest videotape in existence, period, of what went on there.

Q: Wow. The Swiss scientists themselves felt ownership?

LANGE: No, Belgian.

Q: I'm sorry, why am I saying Swiss? The Belgian scientists, themselves, felt ownership?

LANGE: Yeah, a guy named S.R. Pattyn, P-A-T-T-Y-N, was the head of their, I guess, CDC-equivalent organization.

Q: That kind of fills in the gap a little bit for me for what it might have done had you guys gone forward and published immediately.

LANGE: Oh yeah, it would have alienated the hell out of them, yeah. It would have been an unwise thing to do, even though we had the scoop. Of course, they can't tell you why they didn't pursue the same lines of investigation that we did. The French did EM [electron microscopy]. They had pictures of Marburg--what looked like Marburg, which is, at that time, the only virus that now comprises the Filoviridae family. Maybe they didn't have reference sera to test it, I 00:41:00don't know, but they had EM.

Q: Had the French decided that it was in fact Marburg on their end, do you think?

LANGE: Don't know, but they published. They did their own stuff.

Q: So when you came together to publish in The Lancet, it was a combination of you guys here at CDC--

LANGE: This is strictly Karl and Patricia doing all of it, because Karl is the first author. Actually, the article was written by Patricia, and she put her husband as the first author because he was the one running the international commission. She could have been first author on it if she wanted to, but she yielded to her husband on that. I doubt if they even discussed it, I think she just put his name up there. He participated, of course, in the review and the rewrites, but of course, once he saw his name first, he wasn't going to say no, no, no, you put yours first. [laughter]

Q: Was there some sort of politics of how people--how seriously people take women in science behind that?

LANGE: I don't know. I don't know. Patricia was well-respected, and she had a track record herself. Karl contracted hemorrhagic fever from a--a hemorrhagic fever called Machupo virus in South America, Bolivia. And then about ninety days later, infected Patricia with it venereally, and that's also published information in The American Journal of Tropical Medicine and Hygiene.

Q: Oh my goodness.

LANGE: So I'm not sharing any salacious information. But what was interesting about that was that was one of the first descriptions, if not the first, of venereal transmission of a viral hemorrhagic fever from seminal fluid, long after the person recovered.

Q: Of course, that becomes interesting looking back from what happened in West 00:43:00Africa, when we had suddenly this huge explosion in case numbers and seeing more [sexual] transmission of Ebola--

LANGE: Long after the fact.

Q: Long after, like longer than anybody thought.

LANGE: Yeah. I have not seen any of the semen testing data that they did follow-up. But I know they found fragments of viral nucleic acid material, but I don't know if they actually found intact virus. The gold standard is you take a semen sample and you put it into African green monkey kidney cells, and if you can grow a live virus, you say well, that's all they need to transmit. The fact that you have a fragment of RNA [ribonucleic acid], which these are RNA viruses, that doesn't necessarily mean it can be transmitted.

Q: That makes sense. Even though this little fragment might last for months and months, it doesn't necessarily mean it's transmittable.

LANGE: Yeah, yeah, it's just survived that long.

Q: I've got to get Barbara Knust back in here at some point. [laughs]

LANGE: Yes, yes, that's true.

Q: Yeah. Okay, thank you Jim, that helped clear some stuff up for me there. In your conversation with Paul with StoryCorps, you then talked about how Karl Johnson and Patricia Webb, their directorship of Viral Special Pathogens, it transitioned to Joe [Joseph B.] McCormick.

LANGE: It did. Karl, in the late seventies, wrote a proposal that the US Army agreed to fund to open up a viral hemorrhagic fever study site in Sierra Leone, in the eastern province of Kenema. He got Joe McCormick to go out to West Africa and run that show for him. Joe McCormick did the initial work on the first 00:45:00antiviral testing with Lassa-virus-infected patients, and showed that if you catch them early enough, you can save lives with it even though it's a very toxic drug otherwise. If you catch someone early on in their course of disease, between the time they are infected and the time they show symptoms, you can save some lives with it.

Q: What treatment was that?

LANGE: Ribavirin. If you understand the biochemistry of nucleic acids--

Q: Which I don't. [laughs]

LANGE: You don't have to. All you have to understand is that the building blocks of both DNA and RNA--deoxyribonucleic acid for DNA and ribonucleic acid--those two major components are made up of nucleosides and nucleotides, that's just the 00:46:00name for other chemicals. Ribavirin is a nucleoside analog that is part of the building material, building block material that goes into an intact RNA molecule. What you're doing with these analogs is you're playing a numbers game. If you've ever heard the term "Poisson distribution," it describes how fish, for a lack of a better word, are distributed in water by numbers and where they are. Well, the Poisson distribution math also applies here. You're throwing in defective building blocks. This nucleoside analog will go into the assembly machinery that the virus hijacks to make more of itself, and the RNA that comes 00:47:00out with that defective building block cannot itself be replicated. But when you're doing that, you're also introducing this defective building block into literally a sea of perfectly competent building blocks. So again, that's where you're trying to effect a balance between the bad building blocks that you're injecting into the patient and the good building blocks that are already there. You're trying to tilt that in favor of getting more bad building blocks into what becomes replicated RNA than good building blocks. And while you're doing that, you're giving the host immune system time enough to start kicking the virus out. That's the strategy behind it.

Q: Buying time, sure.

LANGE: That's all you're doing. If you can keep them alive just long enough--the 00:48:00immune system, if you look at all viral infections, fortunately for us, our immune systems can handle them. No virus that I'm aware of has ever been described as killing one hundred percent of everything it infects. The initial Ebola outbreak, the numbers were in the high eighty percentiles, but that came way, way down with virtually the same descendent from that virus later on with the proper type of support.

Q: Right. So Joe McCormick kind of takes over--

LANGE: He took over the branch because Karl went up to USAMRIID [United States Army Medical Research Institute of Infectious Diseases] and Patricia went to West Africa herself.

Q: Oh wow. Out to Sierra Leone?

LANGE: Yes.

Q: That's neat. When that came up in your interview with Paul, Paul said, "And then it all went to Hell." [laughs]

LANGE: Oh, with McCormick.

Q: With McCormick. What does that mean?

LANGE: It was difficult working conditions that I believe there were--by the time we had something between fifteen and eighteen people who had been members of the branch, nine of them departed including myself to get out of there.

[break]

LANGE: I went to graduate school in 1979. I went to UNC [University of North Carolina] Chapel Hill.

Q: Oh, you did?

LANGE: Yes, for four years. He was gone--actually, he wasn't gone when I came back in '83, so it was a while after that before he was gone.

Q: At UNC, were you able to further refine your specific interests into a certain area?

LANGE: There, I was really just pursuing a doctorate degree and trying to learn what I could. I did my doctorate studies in a department of pathology in a medical school. The fun part for me was that we had to take courses with med 00:50:00[medical] students in pathologies, organ systems, of course histology to start out with, and so I got to see a lot of how doctors get educated. I went to all of the clinical pathologic conferences, which teach hospital staff what actually happened with their cases, for people who died, and they got autopsy permissions. Especially for surgeons, that's really neat stuff to see. And then to all of the medical grand rounds, which is really cool stuff to sit through for four years. That was fascinating. It's stuff I probably wasted a lot of time on, but I still learned a lot from it. Then I did some studies of rickettsial disease, specifically Rocky Mountain spotted fever, which is highly endemic in North Carolina. We published, I think, three papers while I was there. I did 00:51:00that under Dr. David [H.] Walker, who left UNC and went down to the University of Texas Medical Branch, which became a mecca for infectious disease studies in general.

Q: Galveston?

LANGE: And has their own BSL-4 lab [biosafety level 4 laboratory] now. All thanks to Dave Walker's leadership.

Q: So you come back to CDC, did you say in '83?

LANGE: Yeah, in '83, and Joe was still in charge. I think it was '89 before he got out, '89 or '90.

Q: When you came back, in what capacity were you coming back?

LANGE: As a member of the Special Pathogens Branch. That's when I did the platelets studies and the other thing. And then I saw an opportunity to go work overseas as a--not as a staff scientist, but as a science advisor to what's 00:52:00called the Middle East Cooperation Project, it's called the Middle East Regional Cooperation Project, that promotes scientific collaboration between scientists in Egypt and Israel. I was posted to a university in Cairo, just outside of Cairo, and worked the better part of two years there. When I came back, I left Special Pathogens.

Q: Where did you go after Viral Special Pathogens?

Q: The Division of Laboratory Systems in the Public Health Practice Program Office. It deals primarily with laboratory regulatory issues, technology advances used in laboratory diagnostics, and serves as the advisor for the now-national regulatory framework called CLIA, Clinical Laboratory Improvement Amendments. Until 1988, clinical diagnostic laboratories were not regulated in 00:53:00the United States, other than labs that exchanged specimens across state borders. There was a CLIA regulation for interstate laboratory testing. When CLIA '88 came into being under George H.W. Bush, there had been a huge movement based on media reports of laboratories reading Pap [Papanicolaou] smears in really poor ways, indefensible ways. People being forced to read too many Pap smear slides in a day, people being forced to take them home, which is completely illegal now--it wasn't then, but it would be now. That was the impetus, Pap smears were the impetus for CLIA '88, and probably still is part of 00:54:00it, although the Pap smears are losing favor with the advent of molecular testing technology for HPV [human papillomavirus], which is known to be the primary cause of cervical cancer. But anyway, Pap smears did prevent a lot of cancer [deaths], but Pap smear slides were not being handled properly on a national scale. Most places were doing excellent work, but just enough were not doing it the right way to raise the bar, and Congress got a hold of it and so they passed a law, it got signed, but didn't get implemented until '92. From there, of course, all clinical testing is now federally regulated. Congress, in its infinite wisdom, assigned responsibility for that regulatory administration 00:55:00to what was then called the Health Care Financing Administration or HCFA, which is now called the Centers for Medicare and Medicaid Services, CMS.

I faecetiously call CMS a money laundering outfit, in a joking way. What they do is they administer all the Medicare tax money that comes in. When a Medicare provider sends their electronic bill to CMS, CMS transfers those funds from its account to that provider. That's their primary purpose. They administer Medicare and the government's part of Medicaid, because Medicaid is a combination of federal and state. They handle the money, and that's why I jokingly say they are money launderers, which they're not, of course. But that's their primary purpose. But they are not structured in any way to regulate medical testing 00:56:00laboratories. They had to start hiring people, and ever since--the thing [CLIA] was put into effect in '92, it had a memorandum of understanding with CDC, [with CDC getting] some of that CLIA money. CLIA was one of the first so-called self-financing regulations. Labs pay CMS a fee, a fraction of a penny, for every lab test they run. CMS collects that to administer CLIA financially, and they give CDC anywhere from five to ten million dollars each year to assist them with advising with regulatory language changes, the whole schmear, on a scientific level.

Q: So this is the kind of work that you're involved in--

LANGE: It was the kind of work I was involved in until I got shifted from there to emergency response and preparedness.

[break]

Q: I am here with Dr. Jim Lange, talking about his career related to viral 00:57:00hemorrhagic fevers and now getting into his West African Ebola response work. Dr. Lange, do you remember what you were involved in prior, like immediately prior to getting involved in the Ebola response in Liberia?

LANGE: Yes. I can't remember the specific year, but we had assumed responsibility for a laboratory-focused emergency risk communication function that became part of the Emergency Operation Center's Joint Information Center. We had a small desk--not desk, but seat--within the Joint Information Center called Laboratory Operation Communication System, or LOCS. We were involved in a 00:58:00number of activations that involved laboratory diagnostics whereby we communicated, in our case primarily with the private sector communities within the laboratory community, and we used vehicles such as the professional organizations like the Council for Office Laboratory Accreditation, College of American Pathologists. Early on in its history, clinical laboratory diagnostics was the almost-exclusive purview of pathologists. That's no longer the case, it's branched out to other professional groups besides pathology. But pathologists do cover all the bases of it, they still can. Anyway, we communicated primarily with private sector groups because the Association of Public Health Laboratories, which CDC funds every year--they handle the public 00:59:00health laboratories, so we didn't need to be redundant on that front. I was already intimately involved in and had been conversant with what's called health risk communications. and initially, as I said, I was scheduled to go to Liberia, West Africa, to support CDC's health risk communications effort in support of the Ebola outbreak in October. October was way downstream from--the outbreak had started in February/March. The outbreak was still going on, there were still lots of pop-up cases, both urban and suburban and even rural areas. As I said, when I arrived, I was asked by Dr. De Cock if I would support an epi group 01:00:00because they were short of people. They had, instead of one rotating back, two people were coming back at the same time, and it was leaving them with no one in Bong County. At that time, the person who was running the epi effort in Liberia, Dr. Kim [Kimberly A.] Lindblade, who always led from the front, helped me get my feet wet. Then, of course, we would always submit reports to her on a weekly basis through our reasonably good communications system that had been set up there on what was going on in Bong County.

Q: What do you mean that she helped you get situated? What kind of information were you--

LANGE: She described what we were doing there, what the level of effort was and what our focus should be. What our focus was, at that particular time, was we were checking on those who had been hired to monitor close contacts of known 01:01:00cases. The term that I came up with for that was "checking on the checkers." These people were local nationals who were hired to--in cases where they had the instruments--to record temperatures of known close contacts of every Ebola case that they could possibly identify as close contacts. They had paper, stubby pencils, they wrote down names, they wrote down temperatures, and they had extensive charts that they were supposed to fill out for a total of twenty-one days on each one of these. What we were supposed to be doing was finding out how well they were doing it. When we actually went to the field, we found that there were some gaps in their efforts: that they were not doing or practicing their due diligence on a daily basis; they were doing it every second day, sometimes 01:02:00every third day, and at times, not recording temperature, just simply asking, anyone in this household spiked a fever in the last three days? So we had to go through some corrections after those.

The other thing is, she tried to and was very effective at getting groups to collaborate and share information so that people wouldn't just be operating with blinders on in their particular zone or district within a county. In addition, what was going on in adjacent areas, so that they could at least keep people informed about what was happening around them. She actually led some of the treks into the hinterlands where they did follow-up investigations on contacts 01:03:00of pop-up cases in extremely remote areas where you had to walk. There was one that was over a four-hour walk through pretty difficult conditions.

Q: I had the privilege of talking with Kim several months ago now, or Dr. Lindblade I should say. Geleyansiesu or some town like that, she described her and some EIS [Epidemic Intelligence Service] officers going out. I encourage listeners in the future to also check out Dr. Lindblade's interview because--

LANGE: Yeah, you'll find that highly fascinating. That was really where the rubber met the road in terms of keeping a lid on things and tracking the potential for further problems. What Dr. Lindblade did was identify and model a system whereby these contacts were followed up, good records were kept on those 01:04:00follow-ups, and they knew potentially where any problems might exist because if one of those contacts spiked a fever, they immediately got them to the triage at the Ebola treatment unit and decided whether or not they needed to go into the treatment unit or whether or not--because you've got to understand, Ebola didn't pop up its ugly head by itself, it popped up in a virtual cornucopia of infectious diseases. There are tons of other circulating problems that cause febrile illness in that part of the world. What they had to do was tease out what was real and what wasn't, and they did a very good job.

Q: Was it pretty quick once you got into Monrovia that they sent you out to Gbarnga?

LANGE: Yes. I was there within forty-eight hours.

Q: Within forty-eight hours? Do you remember--if you look back, what did you think about Gbarnga when you first got in there?

LANGE: It looked like the wild wild West to me, especially with all these young men sitting on their little motorbikes, what I now call the Uber-lite taxi stand. [laughs] How else could you describe it? They were taxis, they were taxi drivers, and I just called them Uber-lite because you were riding on a little motorcycle rather than a taxi itself. What really impressed me is that these guys all had cell phones because they would take calls and come pick you up.

Q: So you were staying at the Passion Hotel?

LANGE: Stayed at the Passion, yeah, and hooked up with the Naval Medical Research [Center] laboratory branch personnel who were there for the duration. They had been there for many, many months when I got there, and they stayed 01:06:00there for many, many months after I left, and they ran the entire diagnostic effort in the Huntington University science department facility that they set up their diagnostic lab in.

Q: That's something I want to know more about. [laughs]

LANGE: Okay.

Q: Sorry. These are Naval Medical--

LANGE: Yeah, they were all from the Naval Medical Research [Center] laboratory.

Q: Like NAMRU [Naval Medical Research Unit]?

LANGE: No, NAMRU is a field station system set up by the Navy a hundred years ago.

Q: And there's a number of them around.

LANGE: Yeah, they're down to either three or four. I actually worked--when I was posted to Egypt and Israel, I did a lot of collaborative work training Egyptians at NAMRU-3 in a suburb of Cairo called Abbassia. It's a really cool place. In fact, the guy who, along with Charles [C.] Shepard, discovered Legionella 01:07:00pneumophila--Joe [Joseph E.] McDade, Dr. McDade--he was posted to NAMRU-3 in 1973 when the war started, the Yom Kippur War was initiated, and he saw rockets and jets flying all over the place. They were evacuated, of course, but he was working at NAMRU-3 at the time. It's still there, by the way.

Q: Is it related?

LANGE: No, this is the Naval Medical Research [Center] laboratory, it's one of their chief research facilities, it's located on the Bethesda campus.

Q: Okay, up north in Maryland.

LANGE: It's in Maryland, it's right across the street from NIH. It's on what's now called the Walter Reed [National Military] Medical Center Bethesda campus. Because Walter Reed used to be located further away from Bethesda Naval Medical 01:08:00Center, and they combined into one facility. I think they still use the name Walter Reed though.

Q: Okay, so this naval medical group, they're--

LANGE: Yeah, they were the lab folks that did all the testing on all the specimens.

Q: In Bong County?

LANGE: Yes, and from some others.

Q: And from some other counties?

LANGE: Oh yeah, they did it for multiple--they took all the diagnostic specimens from multiple Ebola treatment units. And they would run tests multiple times a day so that people could get their test results as quickly as possible. As I said, they brought people into the Ebola treatment facilities but didn't admit them to the treatment units until they had confirmation that they, in fact, had Ebola. They didn't want to bring someone who didn't have Ebola into the Ebola treatment unit for fear of exposing them to Ebola.

Q: Right, right, of course. Do you remember any of those guys who--

LANGE: I'll have to send you the name in an email, Lieutenant Commander [Nath] Vishnu. I'll send it to you.

Q: That would be brilliant, thank you.

LANGE: He's now at the Naval Air Station in Jacksonville, Florida. In fact, a group of five guys, and I was able to send them all CDC t-shirts.

Q: Right on. [laughs] Did you go up to Gbarnga with another CDCer?

LANGE: No, I went by myself. As I said, three days after I got there, Dr. Patrick Moonan from TB [tuberculosis] came in, and he's a true epidemiologist.

Q: There we go, that's right. You had said to Dr. De Cock, "I'm not about the epidemiology part," and he said, "Talk to Dr. Moonan and you will be good."

LANGE: Yeah, Dr. Moonan took good care of me.

Q: Can you tell me a little bit about that? Is it somebody who's--a lab person 01:10:00throughout your life--

LANGE: Oh listen, it was a little daunting at first, but it wasn't real complicated stuff. It was simply going from person to person to person, taking temperatures and recording it. All we were doing was seeing how that modeling was being applied, and was it being applied properly.

Q: Was there some suspicion that it was not before you got there?

LANGE: No, we were just--in the laboratory world, you try to exercise as much quality control as you can. All that we were doing was a quality control measure. That's all it was. And as I described to you, later on, we visited what is officially named Taylor Town, named after the--

Q: Charles [M.G.] Taylor?

LANGE: Charles Taylor, infamous president, who still sits in prison as we're speaking, and that's where I met Rachel [S.] Jarteh.

Q: Can you tell me about Rachel?

LANGE: We were hooked up with Rachel at the Passion Hotel. I don't know where Rachel was based, but they drove over to the hotel, and Rachel and her driver would convoy with us to wherever we went. Then Rachel, who looked like she was one of us because she didn't speak a lot, would simply gather information while we were there and then explain to us exactly what happened while we were there because she would be listening to all the back-channel chatter that would be going on. One, anytime you went to a village, you had to go to the village chief to pay the proper respects, and then to get permission from that chief to do whatever you needed to do in that village. It was standard procedure. You never walked in and said, "We're here from WHO, blah-blah-blah, we're the big shots 01:12:00and we're going to do what we need to do." You always got permission, and you were very diplomatic. That's where we learned that the village chief's wife had been infected and died from Ebola from one of their own healthcare workforce personnel who lied about his son's infection. She went to visit the son, as a village chief's wife might, and got infected and died.

Q: Oh no. This is in some village outlying--

LANGE: Taylor Town.

Q: It is Taylor Town, alright, Taylor Town.

LANGE: Yes, right off one of the main highways. It was not far off the main trail to Bong, to Bong County from Monrovia. The road, by the way--when I was in Viral Special Pathogens, I was one of the few who never went to the field 01:13:00station in Sierra Leone. Even some of my other lab-mates got to go. I was very jealous of that, but I can't forget hearing and seeing slides of the horrible roadways that they had to traverse to get to the field station in Kenema from Freetown. It was awful. It would take them days sometimes to get out there. And now, there are these beautiful asphalt super highways, I call them, for that part of the world, that were built by the Chinese.

Q: That's right.

LANGE: And the quality of the work is good. Their engineering fell down in a few places because they didn't account for the excessive rainfall on one side of a highway versus another. These torrential tropical downpours would flood just one side, and it would build up and then overflow to equilibrate from the other 01:14:00side. And in that process, wash out the hard top, wash out the road bed and everything else underneath it. What they had failed to do is put in the proper size and number of what we call "culverts" to allow that equilibration without the water building up. So there were a number of areas that were extremely bad in patches along that well-paved road. You saw it.

Q: I did.

LANGE: You experienced it. By the way, they were putting those culverts in as I was leaving.

Q: Were they?

LANGE: These culverts were a diameter larger than this room. They were so tall. You must have seen some of that.

Q: Yeah, I did, installed. Were the workers--did they appear to be local, or did they appear to be Chinese, did you know?

LANGE: Those were local that were putting the culverts in. What we heard from 01:15:00the local nationals was that they resented the fact that when the Chinese came in to build the roads, they didn't use any local labor, and that was a strong criticism and source of deep resentment for what was truly a wonderful gift to the country. But again, no matter how much good you're doing, the rule says that one bad deed negates a thousand good ones. Obviously, that applies in stuff like foreign aid. Listen, I've seen so much of the same--I saw it in Vietnam, I saw it in Iraq, and we're still seeing it. We can do a lot of good things, but if we screw up, then we can flush all the good stuff we've done in an instant. And 01:16:00that's exactly what happened to the Chinese. A good example of that is when I arrived in Monrovia, it was what you call a gaggle, it looked like complete chaos in the receiving area, the passport area. As we got off the plane, it was obvious that a plane had come in from the People's Republic of China, too, either just before or maybe just after we did. There were lots of Chinese personnel in the same gaggle. And the Liberians grabbed each one of the Chinese and pushed them all the way back to the room and said, you have to wait. And there were some of those Chinese who were coming in for Ebola response work. They were big names in their own right, in their country and probably elsewhere, and they were insulted to be treated that way. I actually felt bad for them 01:17:00because they had gotten in the line before we did. They were told, these Americans go before you.

Q: That's awkward.

LANGE: It is. We did what we were told to do, but it certainly didn't--we were not in a position to say oh no, no, no, we're okay, we'll stay where we are, because that would have caused even more of a ruckus. We just went with the flow, let them handle it. The Chinese, to their credit, their everlasting credit, you could see the embarrassment on their faces, they just quietly walked back to the end of the line, no big deal. But of course, boiling inside, I'm sure. Had that happened to Americans, man, it would have been a knock-down drag-out [fight]. You would have had to get heavy equipment to move those Americans to the back of that line. [laughter] There ain't no way an American is 01:18:00going to do that. I got here first and you're telling me I've got to go to the end of the line? Good luck with that. That's just not part of our culture.

Q: Not really.

LANGE: No, if we get in the queue ahead of everybody else and then some local yokel comes up and says hey buster, you've got to go all the way back to the rear.

Q: Yep. It's true. Even when I get my haircut, I'm very aware of everybody who was there first.

LANGE: Oh, you don't take a number?

Q: No, I don't, it's a local barbershop. But they're pretty good about knowing. Okay, so anyway--so Taylor Town, did that information about the chief's wife, did that change how you interacted with the chief?

LANGE: No, no, because he was very nice. He was nice, but you could see he was heartbroken. He was in pain, and this was weeks after it had happened. He was still suffering grief from the loss of his wife. And of course, the reason we 01:19:00were there is, not only were we checking on checkers, but there had been multiple efforts via social mobilization, the healthcare--I call them the "healthcare talkers," to go into that village and try to convince those villagers who had burned down the house of the healthcare worker, their neighbor who had deceived them and caused such grief in their midst. I guess the guy, once they set fire to his house, got out of Dodge, but they were trying to convince them to let him come back. And by the way, they did. They forgave him. I don't know if--I can't say they forgave him, but they at least grudgingly said okay, we agree, this is the only place he has to live, the only place his surviving children have. Because the child infected siblings that died. The child infected the mother, siblings, who all died. The child had gotten it from 01:20:00his grandmother in Monrovia, came back--the father went to Monrovia, brought the child back sick, showing symptoms, wet symptoms, and lied about it. So when all these other side-effect deaths, I'd guess you call them, happened, the villagers went and burned him out. Said, you ain't living here anymore. You're an evil spirit. And that's one of the things though, Rachel was so helpful, she was telling us where the villagers were shifting in their beliefs between good spirits/bad spirits, trying to decide where we fit in.

Q: Really?

LANGE: Yep.

Q: Interesting.

LANGE: Yeah, because there was one guy in the background who we found out after the fact was what we would call the town drunk. He was drinking that local liquor--I can't remember the name of it.

Q: One of those banana liquors or something like that? Palm wine maybe?

LANGE: Yeah, he was obviously drunk, but he was yelling stuff in the background the whole--he followed us everywhere we went. He was yelling stuff in the background. I asked Rachel afterwards, "What was he saying?" Because we couldn't have that conversation there. She said he was just saying, "Don't believe them, these people are devils. They are lying to you, don't believe a word they say." Of course, there, people don't say hey guy, hey buddy, shut up. That's just not part of the culture there. They just let them have their say and ignore them and go on about their business, which to me is smarter than what we do.

Q: Create an incident, yeah--what we do is create an incident.

LANGE: Exactly. We are too confrontational.

Q: Yes. Are there any other instances of maybe advice that Rachel gave you about how to navigate the culture and delivering a health message?

LANGE: She was a quality control measure in and of herself. If we had gone in and said, "We need to go to this, this, this house, can you direct us toward them," she would have made sure that we understood that that's not how we operate. We go, "Where is the village chief's house, and could we set up a meeting?" In this case, we had arranged a meeting with the village chief. He met us at a community-center-like place. Everything was set up before we got there. But if we had gone in and said, "We're the big bad dudes from CDC and we're here to help you kick Ebola in the rear end," she would have said, "Let's chill on that. Let's find out where the village chief is and beg the chief's indulgence and see if the chief can meet with us and be very nice about it." So yeah, just 01:23:00a resource that does everything in our own interest that translates into the interest of the people we're trying to help.

Q: Right, absolutely. So while you're still there, are some of these re-trainings for some of the contact tracers able to take place where--

LANGE: Yes, they were. In fact, when we got back and did our little powwow, the participant from WHO who did the initial training said, "I'll schedule re-trains here for these people." I asked the question, I said, "If they're not doing their job, why don't we replace them?" And they said that that wasn't feasible at the time. They knew more than I did about it. I was thinking like an American, let's fire this so-and-so and replace him with someone who'll do the work properly. I asked them also, I said, "Did they explain why they weren't 01:24:00doing it?" "Yeah, they said they need a motorcycle or some type of other transportation," which wasn't going to happen.

Q: So some transport issues for people?

LANGE: Yeah, but it wasn't realistic. The places they had to cover were within walking distance in our opinions.

Q: Oh, interesting.

LANGE: Yeah. They were lazy or fearful or a combination of those two, who knows. We didn't say that, either--Rachel wouldn't have let us do that. If we had said "you lazy so-and-so" to these people, "we're going to cut your pay" or something like that, that would have been the wrong thing too. Again, I would use this as a generic paradigm. If you're working in a foreign country and you can locate someone from that area who can facilitate what you're doing and help you 01:25:00navigate, man. If you don't do that, you're crazy, because she saved our bacon in more ways than one.

Q: That's awesome.

LANGE: Yeah, it is. It is. I'm sure she did the same thing for the Peace Corps volunteers that she was assigned to support.

Q: Oh yeah, I'm sure she still does.

LANGE: Because they come in with completely blank slates. I don't care what they read in the CIA [Central Intelligence Agency] books or other publications. You don't get a feel for a culture until you're immersed into it. And she's fantastic for stuff like that. She's very forthcoming--she doesn't hesitate to tell you what she thinks, so that's all you can ask for. Whatever they're paying her, it ain't enough. [laughter] Because I know they pay--actually, by national standards, she's extremely well paid. On a local economy [level], she's doing 01:26:00quite well.

Q: That's good, that's good. Do you have any idea of whether that contact tracing improved after those re-trainings?

LANGE: Yeah, there were follow-up checks. You never stop the quality control. The whole time, that process is going on. The part about it that astounded me the most was these people didn't try to cover up what they were not doing. If they didn't go, they didn't fill that line in on that date. There would be lines filled in, two blanks and then a line filled in. And I'm thinking to myself, man, if I'm not going, I'm writing something in. I don't want my butt in trouble. But I didn't say that to them. [laughter]

Q: No, of course.

LANGE: But that's what we would do.

Q: Of course, yeah. I know every day when I falsify documents, I--

LANGE: That's funny. You know, in today's New York Times there's an interesting article about the popularity of computer coding classes on college campuses. And a large percentage--I shouldn't say large, but an astounding percentage of kids either copy codes from their classmates or go on the internet and find codes and plagiarize and turn that in as being their work. And of course, the profs [professors] have all these programs, these apps that can identify that.

Q: Exactly. That's ridiculous.

LANGE: Even at places like Harvard [University]. I find that funny.

Q: That's a good point, that yeah, maybe there are some people out in Bong County who weren't following up on all of the contact tracers--

LANGE: Oh, there were a bunch.

Q: --but, there are maybe Ivy League students in America doing the same thing.

LANGE: Exactly. That's human nature. You're going to find deficiencies no matter where you are on the planet. But the important thing is that there was QC [quality control] follow-up. There was re-training, QC follow-up, and most importantly, blind ass luck on our part with no secondary cases among the people they weren't checking on.

Q: Yeah, that's awesome.

LANGE: That's the part where you go whew, we dodged a bullet on that one.

Q: No doubt. Okay, so you wrap up in Liberia by December.

LANGE: Yes.

Q: Can I ask, did you have any more contact with Kevin De Cock during that time?

LANGE: Yeah, yeah, in fact, we had lunch. He went back, I forget what for. One of our former Special Pathogens mates, Luanne [H.] Elliott, organizes a luncheon 01:29:00every Christmas, and Kevin happened to be in town for one so he attended.

Q: Nice.

LANGE: Yep. It was over at that Mexican Restaurant on Piedmont. Del Sol?

Q: Yeah, right, Taqueria or whatever.

LANGE: Taqueria del Sol, yeah. He was still the boss of CGH [Center for Global Health] at the time. And then, because of I think his kids, he had to go back to Kenya. The last time I saw him, he said I think his oldest was in college somewhere in Wales.

Q: And then from there, it's the five trips or so as part of STRIVE.

LANGE: Yeah, STRIVE came onto the scene, and that was interesting stuff because I had to work with a group of six Sierra Leoneans, who for the most part were 01:30:00really good to work with. The only problems we had were with the supervisor that was chosen, and we developed work-arounds for that.

Q: Like what was going on?

LANGE: He was interfering with their workflow. We'd come in in the morning and there would be people waiting to be bled, volunteers. Well, the supervisor would require them [the staff] to go through their cleaning chores before attending to the people waiting to be bled. I tried to explain to him, the supervisor, that the person waiting to be bled is the equivalent of a customer, and the customer should be served first. Then, once the customer is taken care of, you can do all the cleaning you want. He wouldn't agree with that, so I would have to step on his toes slightly and say, we're going to take care of customers first. It was 01:31:00funny because I got all the Sierra Leoneans to say, "What's the most important thing?" "Customer first!" [laughter]

Q: Really?

LANGE: Yeah. It was funny, and they laughed too. They understood. But they could never speak up against their boss, who was just selected to be their boss for that period of time. In that hierarchy, it would have caused them more grief than it was worth to say, I'm going to go get the customer first.

Q: Was there a particular Sierra Leonean who you really bonded with or talked with a lot that you can recall?

LANGE: The one I spent the most time with is a Muslim kid named Muhammed [Kamara]--I'll have to look up his last name, I'm forgetting at the moment. But I tried to help him with his interview in an application for a visa to come to the US, and I tried to explain to him that he was making a mistake on his 01:32:00paperwork, thinking that the fact that he claimed on his paperwork that he was a Christian would help him get entry into the US. I said, "Tell them the truth, it doesn't matter whether you're Christian or Muslim, it's not going to help you either way." His interview was a disaster, so it didn't work out at all. Because he was a bright kid, he has the type of phlebotomy skills that there's a shortage of here. So he could get in based on his technical skills, but when you have a callused tissue up here--

Q: On your forehead?

LANGE: Yep. It's an indicator of piety among Muslims because when they pray, they press their forehead to the floor. The harder you press, of course, the more callused tissue you build up. That's what happens when you put pressure on 01:33:00any part of the body. It was obvious to whoever he talked to at the Embassy, they knew what was going on. But the kids were good. We had one young lady who suffered a bout of malaria on our lab staff, and that was a scary thing to see. One of the "matrons," as they're called, who was in charge of the building where the vaccination, the phlebotomy, and the out-processing and payment for participation all occurred. She came down with two bouts of malaria while I was there, and that was really scary to see how sick she was. They suffer bout after bout after bout.

It was a good experience. And we got four-hundred-and-some-odd participants.

Q: Yeah, that's what you were saying, that the number was jumping around a little bit in terms of what people thought could be scientifically--

LANGE: Yeah, I don't know what the origin of that was, but Dr. Jane [F.] Seward, who was the field chief when I first arrived, real good to work with and for, smoothed things over quite well.

Q: Were you, in that immunogenicity sub-study, able to come up with--what kind of results did you see at the end?

LANGE: The only result that we saw was the number of participants. What you had to do was first of all, ask for volunteers to participate in the immunogenicity sub-study, understanding that people from other cultures don't necessarily like 01:35:00having their blood drawn from them. There's a negative connotation associated with that process. Even after we got signed names on forms, they would say no, I think that's too much blood that you're going to take out of me. Some of the young girls were saying I'm on my menses and I don't want to lose any more blood. So our health communication specialist, Amy [L.] Callis, set up a diorama for them to show them how much blood there is in your body, how much we're taking, and that illustrated to them how little blood we were withdrawing. I don't know what its net effect was, but after that, we got less excuses like that, that you're taking too much blood. It seemed to work.

Q: But were you testing to see if there was an immune response?

LANGE: See, that's the hardest part. Merck [and Company], the owner of the license--the vaccine is produced in Canada. Merck bought the licensing for it here. So Merck controlled the specimens by agreement with CDC. And Merck hasn't tested a single specimen yet. There's a whole bunch of reasons for that. The primary reason they say is they're having trouble with technical validation for the test their using. It's called ELISA, are you familiar with that acronym?

Q: Yeah, I've heard that.

LANGE: Enzyme-linked immunosorbent assay, that's what it stands for. It's just one of the many ways of measuring humoral antibody in blood, and in this case, it's in serum that we separated out because that's what the lab did. It drew the blood, separated the blood from the liquid, aliquoted that liquid into as many 01:37:00as six vials, and then shipped it all back here. Now, it's with Merck, and they're going to start--they're supposed to start testing this month.

Q: Okay, that's good. Do you have any thoughts on what was announced about how effective the vaccine was from the ring trials from WHO?

LANGE: I'll tell you what, toward the end of my fourth trip there when WHO announced based on very limited numbers in Guinea, a little outbreak in Guinea, that they used the same vaccine for, that they stopped transmission. They said it was effective. The next day, we had more volunteers than the parking lot could handle.

Q: Seriously?

LANGE: Yes. [laughter] Everybody wanted the vaccine, and we had to explain to them, first of all, if you're not a healthcare worker, you're not eligible. Second, if you are a healthcare worker and you didn't make an appointment for 01:38:00today, sorry, can't help you. That was funny to everyone.

Q: Now, I don't know if they've already started using it for the Democratic--the current outbreak that's going on in DRC--

LANGE: I don't have any insight into that.

Q: They were at least talking about it.

LANGE: Yeah, if it looked like it worked in Guinea, why not? As long as it's the same strain, and it looks like it is. It's that one that's a descendent of the '76 outbreak strain.

Q: Right, the Zaire.

LANGE: Yes.

Q: So, looking broadly, in broad strokes, Jim, I want to ask: what kind of changes have you seen in CDC in general since you started in '74?

LANGE: It went from an infectious disease exclusively focused organization to a 01:39:00multitasked organization. That began in the early eighties when Dr. Jim [James O.] Mason was appointed the director, and for the very first time, his appointment required Senate consent, advice and consent, that's what the constitution had--So, once that process started, we went from Center for Disease Control--actually, Communicable Disease Center, Center for Disease Control, Centers for Disease Control, started having chronic and all sorts of other diseases added to our portfolio, and HIV and all of the other infectious processes that kept piling on. And the violence, smoking, social behavior areas 01:40:00of science, so it's a big megaplex now.

Q: What have you seen about how its capacity to assist in emergency responses has changed?

LANGE: That was, again, a new function for it. When I first arrived, everyone on the staff rotated what was called duty officer duty. And that duty officer duty consisted of having a beeper and a three-ring notebook. The beeper was for when a call came in to the switchboard, they'd call you and say they want help with such-and-such. You'd look in the three-ring binder, look up the name of that disease process, find the relevant name of the designated expert under it, call 01:41:00that person however you can, and if you can't get them, get the secondary. If you can't get the secondary, go to tertiary, and if you strike out completely, you go to the epidemiology boss. And that's how we handled emergencies. But also, even then, if some public health department anywhere in the country, matter of fact, anywhere in the world, wanted help from CDC that called in, there would be an EIS officer on an aircraft with all the proper papers, either the same day or the following morning. Which for a government agency is pretty darn impressive to me. CDC has always been what I call a pretty effective first responder. Now, after we first responded to the outbreak of this mysterious respiratory illness up in the [Bellevue]-Stratford Hotel in Philadelphia in 1976 01:42:00at an American Legion convention, that went completely undiagnosed for over a year, we were criticized. Then, we were also criticized in the same doggone year for the swine flu campaign. So not everything has gone smoothly, but the intent has always been there. You know you're working with people who care, they're smart, they're motivated, they're going to try to do the best they can, and they don't care who the hell you are, they'll try. Because they understand that even if the disease outbreak is in the al-Assad family in Syria, that has potential for spreading not only there, but other parts of the world. Even if it's an evil person--the example I use is if we got a specimen in for Osama bin Laden Jr., 01:43:00we'd test it because there might be ramifications, not just for that family, but families all over the globe, if it happened to be the wrong thing.

Q: Recognition that we're all connected.

LANGE: Sure, sure, we are.

Q: I have one last question for you, Jim, and that's, did your participation in the West African response give you any new or unique perspectives on public health work at all? Or was it just predictable?

LANGE: Well, if you listen to what Dr. Frieden said, he said, "We know what the problem is in West Africa, we have tried and true methods to deal with it. Once we get enough resources on the ground there, we're going to start treating 01:44:00patients, stopping the spread and getting it down to zero." And that's exactly what happened. It took time, it took a lot of effort and a lot of money, but--and there was nothing new about that because the methodologies that were used have been around for a very long time, but until they are applied properly--and most importantly, in a setting like West Africa, until the local people start adhering to the recommendations that are brought in, which really goes against their cultural practices in many cases. That's where the rub comes. When people listen to the social mob [mobilization] messages, see all the posters on the huts' exterior walls, sometimes interior walls, telling them if you see a case, what to do, who to call, how to get help. If you're going to have to wait for help, only have one person attend them, take care of them, how 01:45:00to handle waste. If they die, don't go through the usual rituals of having the family and the other relatives and the neighbors. In my area of South Louisiana I've seen people walk up to an open coffin and kiss a corpse right on the lips and not think a thing of it. Now, I don't know if these were all embalmed corpses, but whether they were or not, who knows.

Q: I like that impulse, it's not to exotify but to say--

LANGE: Yeah, yeah, I've seen them pick up the hand, hold it up to their face, and cry. When I first heard about the burial rituals in West Africa and people would stand the corpse up in the middle of a hut and they would come and put their heads on their shoulder and commiserate and talk, what's the difference? 01:46:00Of course, out here, people around me say oh, those people are nuts. How can you say--what do you base that on? What is your experience?

Q: Exactly.

LANGE: I think the prime fault of humankind is being too judgmental and we all fight that throughout our lives.

Q: Was there anything else you wanted to share about your West Africa experience or anything else before we conclude the interview?

LANGE: For me, it brought me full circle from the start of my career to when I retired, just four months ago. I started out with Ebola in the lab and I finished with Ebola in the lab in Sierra Leone, or a facsimile thereof, an Ebola vaccine. It was a lot of fun, and I was very fortunate with stops in between in 01:47:00the Middle East. And a year off, I took a year off from CDC in '06 and '07 to frolic around Iraq. I was a theater laboratory consultant and a civil military affairs officer too, so I visited all of the hospitals we had, which is fascinating, and the blood banks.

Q: Wow, that sounds like it's--

LANGE: And saw antiquities I would never have seen otherwise.

Q: Really?

LANGE: Oh hell yeah. Yeah, it goes all the way back to Babylon.

Q: I hope they still exist.

LANGE: They do, they do. There was a Western base called Al Asad, of all names, a Marine Corps base out in West Anbar. There's a spring that's described in Genesis by Abraham that's as crystal clear today as it was two thousand years 01:48:00ago. His name, you know, by name. Fortunately, it was inside the air base that I was situated on so I could go see it. Pretty cool stuff.

Q: That is pretty cool.

LANGE: You can't make that shit up. [laughter]

Q: And now you're about to go to New Orleans.

LANGE: Yeah, back to my roots.

Q: Another full circle.

LANGE: Yeah, you're right, it's true.

Q: Well, I can't tell you how great it's been having you in here, Jim. This, combined with the interview with Paul Fiorino, I think is going to be a huge addition to our archive. Thank you for that.

LANGE: Thank you for the opportunity to share some of it.

Q: Of course.

END