Dr. Kathy Hageman

Dr. Kathy M. Hageman

Q: This is Sam Robson, here today with Kathy Hageman. Today's date is June 14th, 2016, and we're in the audio recording studio at CDC's [United States Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I'm interviewing Kathy as part of our CDC Ebola [Response] Oral History Project. Kathy, thanks so much for being here with me today.

HAGEMAN: It's great to be here, thank you.

Q: For the record, could you please state your full name, and your current position with CDC?

HAGEMAN: Sure. I'm Kathy Marie Hageman, and I'm the branch chief for Epidemiology and Strategic Information in Zambia, which is in southern Africa.

Q: Thank you. Going way back, can you tell me--not way back. Recently. Can you tell me when and where you were born?

HAGEMAN: Sure. I was born in Iowa, small town of less than five hundred people.

Q: Wow. What town?

HAGEMAN: Lawler, Iowa. Four hundred and thirty-two, I think. One stop sign. No traffic lights. [laughs]

Q: Were you raised there, too?

HAGEMAN: I was. I grew up in Iowa, grew up in a small town, and then went to university at the University of Iowa, got a bachelor's degree in English, and 00:01:00then joined the Peace Corps and was posted to southern Africa, in the country of Botswana, and stayed for three years.

Q: Can you tell me what your parents did when you were growing up?

HAGEMAN: My parents, my mother was a teacher, also an English and history teacher, and my father was kind of a construction worker, built homes, things like that. My mother was a big traveler, so I think that's where I got the interest to travel and willingness to do Peace Corps when I finished from Iowa, University of Iowa.

Q: Were you thinking, I'm going to be an English major, even back in high school?

HAGEMAN: I became an English major because I didn't know what I wanted to do, and I knew it was a transferable degree. [laughs] It was a good beginning degree, when you didn't know what to do, and hence, then I became an English teacher in Peace Corps. So it did have a path. Actually, it was because of Peace 00:02:00Corps that I got interested in HIV [human immunodeficiency virus], which is ultimately how I ended up at CDC, working in HIV. But it was not a direct correlation, of understanding HIV and public health, when I was in Peace Corps. Didn't really know what public health was at that point.

Q: No, of course. Was it Peace Corps right out of Iowa?

HAGEMAN: Yes. I graduated from Iowa in '94, and then joined Peace Corps immediately after that. Stayed for three years, and was very fortunate to have been posted to the Okavango Delta, which is kind of this--the only inland delta in the world, it's a very famous area for wildlife, and environment and safari. I was fortunate to be in the middle of that. Had to take a boat to get to my school, hippos and crocs [hippopotami and crocodiles] jumping at the boat, elephants, lions at night. It was the Peace Corps experience. [laughs] But with that said, so--that was in the nineties, early nineties, and at that time 00:03:00Botswana was reporting HIV infection of thirty-three percent, and amongst women who had children, over fifty percent. Amongst women on [semi-]trucking routes, over seventy percent. I didn't know what public health was, I didn't know what HIV--well, I did know what HIV was, but. I was sitting, trying to teach students, and I'm thinking, one in three of these students is going to get HIV. What do you do? So we started kind of ad hoc, doing HIV education, because at that point the infrastructure in the country didn't have an HIV plan, and so teachers kind of did that. Everyone kind of did that. That is, I think, my first introduction to HIV and public health. Although I didn't realize that was public health. In retrospect, that was public health. Ultimately, then, twenty years later, I ended up, I'm now at CDC, working in HIV in the neighboring country to 00:04:00Botswana. So, small world. [laughs]

Q: Small world, no doubt. Do you remember any students in particular, from when you were there?

HAGEMAN: I do, I do. Yeah. And I remember things like, because I was an English teacher, I would teach grammar. Whenever I could, I would use HIV examples. I remember one day, I was using an HIV example for grammar, and one of the students said, "Teacher, no more HIV. We're tired of you talking about it." [laughs] Yeah. It was good. And then, when--I was able to go back. I was there for three years, and then I was away for four years, and I was able to go back, and then it was sweet because when I went back, I bumped into some students, and they said, "Now we know you care."

Q: Isn't three years a year longer than usual?

HAGEMAN: Well, they have this program where you can do a--it's called Peace Corps Volunteer Leader. I was able to move into that position. Partly because 00:05:00the country office was closing down, and they were trying to--as US government direct hires were, their contract was ending, they were using Peace Corps volunteer third-years to replace them.

Q: What happens after Peace Corps?

HAGEMAN: Then, I still didn't know what public health was, even though I knew I was interested in doing something that had to do with helping people. But I was really interested in history, and I was really into behavior, and I was really interested in anthropology, and social sciences, and, like, what would--what was it, how could I help people, using all of that? Because when you look at the mainstream careers of going into straight development work, then that's like education, or microfinancing, or--or going into the health professions, of a 00:06:00nurse or a doctor, a nurse practitioner. None of those things--those are all great ways to help people, but none of them seemed like a way that was a good fit for me. So, actually, I kind of just did random jobs, I traveled around the world, spent about ten years just traveling around the world, taking odd jobs, until I bumped into public health. And I finally realized that there was a component within public health that was behavioral science. That's where I realized that everything that I was interested in was going to come together.

When you do behavioral science within public health, you have to understand culture, you have to understand history, you have to understand human dynamics, you have to understand cultural dynamics, religious dynamics. All those things that kind of fall under social science and anthropology and psychology. Then you 00:07:00also have to understand public health, in the context of all of these other dynamics, barriers and motivators, how do we get them to do something that we want, or how do we get them to stop doing something that we don't want them to do? Once I realized that there was this component within public health, called behavioral science, I was like, this is what it is. This is what it is. [laughs] Then I started looking for schools. Because of the proximity to Rollins School of Public Health, which is at Emory [University], that proximity to CDC--and at that point, I still had this lingering interest in HIV because I noticed when I was a Peace Corps volunteer that my students really knew a lot about HIV. Which, now, I understand--they understood the epi [epidemiology] of HIV. They understood T-cells, they understood transmission rates, they understood how to get it. There were ABC signs everywhere--Abstinence, Be monogamous, use Condoms--everywhere. But their behavior wasn't changing. Again, not realizing 00:08:00that that's ultimately behavioral science, that's what kept going in my mind. Like, okay, when knowledge is really high, when they're well-educated on a topic, they know what to do to prevent infection on a topic, why don't they just do it? It's the same here. Why don't people wear seatbelts? Why don't people wear bicycle helmets? It's not unique to any one group, but it's trying to understand, for that group, and for that disease, what do we need to do for them? That had been turning in my head for a while. And around, why didn't their behavior change when they had all this education? Then, a few years later, I bumped into literally what behavioral science was, and I thought, this is what I was wondering. This is what I wish I had known when I was a Peace Corps volunteer. Because I was really just re-educating them on stuff they already knew, and trying to motivate them. But I really didn't have the skill set to 00:09:00help them change their behavior, or understand where they were in the process of changing their behavior.

Once I realized behavioral science, and my interest in HIV, and Rollins being close to CDC, I ended up coming to Rollins for my master's degree. My first year at Rollins, one of my professors, Dr. Claire [E.] Sterk--who actually is now president of Emory, but at the time was the chair of my department--asked me, "Do you want to get a PhD?" And I said, "No, because I want to work with people." At that point, I thought a master's degree was when you got to work in the field, and a PhD was when you had to sit at a desk. Then I realized that public health was always working with people. Whether you had a PhD or a master's, you are always working with people. Eventually, I realized, before I finished my master's, I was really interested in research. So I stayed on and 00:10:00got my PhD in behavioral science at Rollins, and continued to do all of my research in HIV in southern and eastern Africa. I always seemed to end up landing back in Africa, and really enjoying the work of HIV and untangling the dynamics that come into play when you're trying to work with an infectious disease.

Q: Was it something that--I forgot the professor's name, Dr.--

HAGEMAN: Claire Sterk.

Q: Claire Sterk. Was it something they said? They said, "No, it's not this division between"--

HAGEMAN: Really, no. We talk, we've talked about it a lot since. She kind of did this--unknowingly, she kind of gave me this look of, you don't know what you're talking about, but I'm not going to challenge you right now because you're going to figure it out really soon that you're going to want a PhD. That you're going to want research, and you want to be at the front end of trying to help make those decisions as to how to change people's behaviors. And that's exactly where 00:11:00I was. I realized that just like everything else in public health, everything is grounded in data. Behavioral science and trying to understand why people do what they do is grounded in data. I realized that's where I wanted to be, I wanted to be on that front end of trying to figure out, what's the right question to ask, how do I try to disentangle culture, and history, and religion, and personal dynamics, and family dynamics, and interrelationship dynamics, to get one person to do one thing that would extrapolate to a population level?

Q: So you talk about bumping into behavioral science. Was there some event, or was there a story behind that bumping into it? Or was it just learning about it through a textbook or something?

HAGEMAN: No. It--you know, it's funny. Because I say about it--I think it was 00:12:00just, I heard it, I got pieces of it in a condensed, short period of time. Before, earlier in life, I thought public health was, don't drink eggnog, and--being from Iowa--don't thaw your meat on the kitchen counter. Because both those things cause bacteria to grow. That's what I thought it was. And really, what that was, was county extension work. I didn't understand what public health was, I didn't understand vaccination rates and herd immunity, and I didn't understand this population way of thinking about how to keep people healthy. Through my different travels, of living in different places, living in the Middle East, living in India, living in the South Pacific, you start to see that there's these systematic things that are happening everywhere. If people don't have bathrooms, there's going to be health consequences to that. If people don't 00:13:00have water, there's health consequences to that. If people don't have money to go to the clinic, there's health consequences to that. If the clinic is too far away, there's consequences to that. If the clinic charges money, and people don't have money, there's consequences to that. I think just, as I moved around to different countries, I realized that there's really consistent themes here, and an individual person's barrier of not having money for one visit at a clinic is a ubiquitous problem around the world, across all cultures. That's when I started thinking about, okay, these are population-level themes in which entire populations are being disadvantaged, and we need to help them. And again, because I wasn't just interested in straight water and sanitation, or straight health policy, or straight maternal and child health, even though I was slowly getting these insights to public health, I wasn't finding--it wasn't clicking 00:14:00for me. Until someone explained to me, there's actually this behavioral science track. It kind of puts it all together. I was like, I want to understand how to put it together. It was great. Going to school felt like going to the playground, it was fascinating. Everything was trying to understand, how do you disentangle someone's life to do what they need? To get them to do what you need them to do?

Q: What did you write your dissertation about?

HAGEMAN: I wrote my dissertation on serodiscordant couples. That's when one [person] is HIV-positive, and one [person] is HIV-negative, and these are long-term couples. You can imagine that when you're in a long-term relationship, married, and one is positive and one is negative, and the couple is told that, and they're also told, "Moving forward, you'll always have to use condoms [to not spread the virus to your partner]. For the rest of your life. And you 00:15:00shouldn't have children because to have children, you have to not use a condom." One, that's not practical. [laughs] Individuals aren't going to do that. I was looking at the dynamics of, how do couples work through that conversation, and that decision-making, moving forward, especially in cultures within Africa, in which the need for children is a social status? It's a status of the man being very powerful, it's a status of wealth. To tell a couple, in a culture that has all of these subsequent markers that children stand for, that they can't have children or shouldn't have children because it would mean not using a condom. Obviously, there's going to be a lot of conversations that happen in the home, that are going to lead to experimentation, of not using the condom, or just 00:16:00choosing to never use a condom. And trying to understand the patterns that they, the decisions they make, the conversations that are had, how--they would go through periods of time in which they were really compliant with condom use, and what were the triggers in which they would decide to not be compliant with condom use? It was just really looking at this group at a really human level. Because no one wants to use a condom for the rest of their life. But that's what serodiscordant couples are told. Science is advancing, and now, with viral suppression, there's hopefully going to be more options for them, and with PrEP [pre-exposure prophylaxis] there's more options for them. But back in--since the beginning of the epidemic, up until now, we haven't had an alternative recommendation for them. We can give great recommendations, but that doesn't mean people will do them. I was trying to understand their challenges, and then trying to help look at it through risk reduction. Realistically, no, they're not always going to use a condom. So what can we prepare them for, to do risk 00:17:00reduction methods, to try to prevent transmission when they choose not to use a condom.

Q: That's fascinating, totally fascinating. [laughter] What year is it, that you achieve your PhD?

HAGEMAN: I graduated with my PhD in 2010.

Q: In '10. Okay. And then what happens?

HAGEMAN: Then, I actually moved away from global work, although that had always been my interest, and I took a position with CDC in domestic HIV, in the Division of HIV and AIDS [Prevention], and worked on the behavioral surveillance team. That was a team where we worked domestically, and we had a behavioral surveillance system for HIV in the twenty largest cities in the US. If you think about what the twenty largest cities are, you're probably thinking of the cities that we worked in. We did behavioral surveillance on three population groups: men who have sex with men, people who inject drugs, and heterosexuals at high 00:18:00risk, which, from the data, were able to be defined as either low-income or low-educated. Each year, we would do surveys and HIV testing in one of those populations. It's been running for probably about ten to fifteen years, the National HIV Behavioral Surveillance system. I worked with them for five years.

Q: You were there, then, when the West Africa Ebola epidemic--

HAGEMAN: Yeah. Yeah, I was working for the behavioral surveillance team domestically when Ebola hit in 2014, and put my name on a list to say that I would like to come out. In December of 2014, I was kind of called up, if you want to call it that. Got an email that said, "We'd be interested in sending you 00:19:00to Sierra Leone. We would like send you for thirty days on the Health Promotion Team." I didn't know what the Health Promotion Team was, but I got supervisor approval and went for--supervisor approval for thirty days. Then the EOC [Emergency Operations Center] wrote and said, "Actually, can you stay for forty-five days?" So I went back to my supervisor, and they said, "Sure, you can stay for forty-five days," and then, fast forward, I stayed for ten months. [laughs] And I figured out what health promotion does, which was good, for having been there for as long as I was.

Q: I want to figure that out, through hearing about your path: what health promotion is and what it does. So, tell me about arriving.

HAGEMAN: Right. Arriving in Sierra Leone--and I'm sure you've heard this from many other people--is a pretty adventurous experience. You land at an airport, which is connected by land to the country. But once you land, you 00:20:00travel--actually, you land, and the airport is hot and muggy. Just hot and muggy. [laughs] At that time, the flight came in at about ten or eleven o'clock at night, and so it's dark, and it's hot, and it's muggy, and you could actually see, when you're outside, steam coming off of people heads when they were standing underneath lights. I remember that the first night. You could just see. It was so steamy there, you could just see us putting off heat from the top of our heads. As we stood, exhausted, having been on this--I don't know how many hours it takes to get there, twenty hours, maybe.

When I arrived in January in 2015, it was still very much the height of the outbreak. Technically, we had passed the peak, but we didn't actually know we 00:21:00had passed the peak. People were still ramping up services, NGOs [non-governmental organizations], agencies, organizations were still bringing people in en masse on these airplanes. I remember, walking, you get into the airport, and you collect your luggage, and it's hot and steamy, and you walk out. Because there were so many people there to--there were so many agencies and organizations that were flying in more team members, there was just this wall of people holding signs. It was every organization you could think of. And I just remember seeing them. There must have been at least twenty or thirty different people holding different signs [like] WHO [World Health Organization], Catholic Relief Services, Doctors Without Borders. I mean, it was everyone who you know works in international health was there. They were just standing across the street, and then you were to go and find your person. For CDC, we had someone who was already helping us on the inside [of the airport]. We got our luggage 00:22:00and we traipsed across the parking lot, and they say, "Stay here," and they take your luggage, and they put your luggage in one vehicle, and then eventually another vehicle comes to get you, and then you--it's under dark night. They take you to this ferry port, and you feel like you're driving through people's backyards--it's an unpaved road, and you're driving right next to people's homes and trees and gardens. You really think, you're driving, are we not driving through someone's backyard? The road's not paved, and the road is bumpy, and it's hot, and you're just hoping that your luggage--you don't know where your luggage went, but you're hoping your luggage will end up where you are. Then they drop you at this ferry dock. Then they say, again, "Just stay here." We don't have our luggage yet, and then this really wobbly ferry pulls up, and you 00:23:00walk up to this wobbly dock, and you get in, and you feel like now, you're in an Indiana Jones movie. Because you're going across the ocean, it's faster to go by boat across the ocean to get to the capital of Freetown than it is to drive around--it's about a three to four-hour drive if you go by road. The airport had figured out to have this boat ferry system. But it's a small boat, like maybe twenty people. The tide was up, and the waves were up, and you're going fast, and it's hot, and you don't know where your luggage is. You're just going with it, and you're going to go and help Ebola.

Then you get on the other side, where you dock, and then your luggage is there in this massive pile. You find your luggage, and CDC cars are waiting on the 00:24:00other side, and they say, "Okay, put your luggage in the car and we'll take you to the hotel." We got to the hotel probably at midnight, and it was hot and it was sweaty, and they said, "[In the morning], go to breakfast, and you start work at eight o'clock."

Q: What, oh my god. Tell me about that first day.

[break]

HAGEMAN: The first week you're there, there's so much going on. It's really hard to even really get your footing. We were still very much in the throes of containment. Like I said, we had technically passed the epidemiological peak, but at that time we didn't really know that we were truly coming down. At that time, Dr. Oliver [W.] Morgan was the acting country director. He had a very set speech, and it was very firm and very unwavering. And that was, "We have a job 00:25:00to do." And then he had this PowerPoint slide, where he outlined the key one or two things that each team was responsible for. What the Epi Team was responsible for, what the Health Promotion Team was responsible for, what the Infection Prevention and Control Team was responsible for. He basically said, "Don't do anything but this, this is your job. You'll find that there's 101 things that aren't working, or that need to be started or need to be improved. That's not your job. Someone else has to do that. CDC's brought in to provide the technical guidance on these areas, and this is your job." I think part of it was really good in--even though you didn't yet understand what was going on, you knew from day one that you had a really specific lane to stay in. Especially when you got 00:26:00out into the villages, there's a hundred competing issues. You have people who don't have food, people who don't have healthcare services, people who are sick, but they don't have cell phone capacity to call for help. You want to get involved in all of that. And you have to trust, you have to remind yourself, and you have to trust that someone else is doing that, there is--all those agencies that you see standing outside the airport, they all have a role and someone else is going to have to do that one. We were here to do CDC's job, what we do really well. We do epi really well, we do data really well, we do infection prevention and control really well, we do communications and behavioral science really well. So that's what we did. I think that really, for me, set the tone. Oliver would just say, over and over again, "Stay in your lane, stay in your lane." If he got wind of something, he would come to the team lead, and he's like, "Tell me how that stays in the lane. Tell me how that gets us to zero." There was a 00:27:00lot of times Oliver would come to me--I ended up being team lead for Health Promotion for most of the ten months I was there, and yeah. Oliver would hear something, he goes, "Tell me how that gets to zero." If you couldn't tell him, it was off the table. It was a really, hyper-focused way of approaching it, but we really had to do it. Because if we didn't get hyper-focused, we couldn't get what we needed to do, CDC's mission, done in the midst of everything else that also had to get done. We couldn't do everything. There was too much to fix, there was too many weaknesses, there just wasn't a lo--there was too little infrastructure, too little everything. But Oliver would just, his mandates. "Does it get us to zero," and "stay in your lane." It was hammered into us. That set the tone, and then--

Q: Can I ask, I'm sorry to interrupt. Was there ever anything specific that you 00:28:00saw that you really wanted to help with, but you just couldn't?

HAGEMAN: I think the one that everybody wants to help with, wanted to help with, was the orphans and the vulnerable children. You had families and extended families that were completely wiped out. Families, maybe twenty people, lived in a house and one or two people survived. Literally, them watching, one by one, their family member getting sick and passing away, and the next one getting sick and passing away. It was hard to see--you would know that there would be all these orphans from this. And just like anything else, there just wasn't the infrastructure. It was no one's fault, it was just, when you have this level of an outbreak that caused this level of impact, no country would have been prepared for this. It was really hard to not want to try to help, to do 00:29:00something. But who's taking care of the orphans? Also, the schools were closed. The kids weren't being educated, they were trying to do this thing where they were having--they had teachers who would give classes over the radio, and over the TV, for those that had TV. It was just things like that, things that we take for luxury, that when you're in a complete outbreak kind of situation, where schools are closed down, stores have limited hours, transportation has limited hours. When everyone is kind of--we literally wanted to minimize movement and interaction with people. There was just things that, you know, weddings were called--I mean, I know this isn't related to your question, but you couldn't have a wedding, you couldn't have a family gathering, you couldn't celebrate the 00:30:00birth of a child. So it was just, there was just a lot of things that were imposed upon people. Some of that played out in true things that really broke our hearts, like orphans, or people who were sick, sick from diseases that weren't Ebola. That was another hard thing because all resources were directed towards Ebola. Some of the other health facility services were then, weren't able to stay at the same capacity. It was hard because you would want to help people who normally were getting care, but the resources weren't there anymore because they had been repurposed for Ebola.

Q: Was there ever, did you have much contact with orphans, or children heavily impacted with--

HAGEMAN: You would--[pause] I think you'd see them [pause] In Sierra Leone, we 00:31:00had a quarantine program, which was, I think, a little bit different from how Liberia and Guinea had it. When there was a sick person, the whole house would get quarantined. That's where we did a lot of our work in trying to understand why the infections continued in certain households, where we would do a lot of the behavioral science investigations. You would get to these homes, and you would see so many more children than adults. And you didn't have to ask. [pause] You just kind of wondered who's going to take care of them. Sometimes they were, 00:32:00I mean, they would fall sick as much as the adults, and so then it was also hard because you would know, eventually, they very likely would get sick, too. And if we couldn't untangle why, we couldn't stop it. What would happen is, we would get these households of twenty people living in the household, and we couldn't stop the chain of transmission.

Really, what it takes is just, as soon as that first symptom appears, they call for help. Which is a really easy thing to say to do. "Just call for help. As soon as you have a fever, call for help." But what was happening is, for various reasons, they weren't calling for help. And in taking care of the next sick person, the next family member got sick. [pause] Sometimes you knew it was just 00:33:00a matter of time, even for the kids. But we would try to get them out before they got sick.

Q: Can you tell me about how your work evolves over the first few weeks?

[break]

HAGEMAN: As I mentioned before, I had come January of 2015. From the look of where the epidemic was going, the country had done a really good job at building up capacity, having a lot of the infrastructure. Getting more of the infrastructure in place. Getting ambulances brought into the country, getting 00:34:00the Ebola treatment center set up, getting the personal protective equipment that healthcare workers needed so they could care for patients without getting sick themselves. Getting medicine in-country, getting beds in-country. Getting all that stuff that you have to get in-country before you can even really get control of the infections. When I arrived in January, we were at that point where, for the most part, a lot of the infrastructure was there. And there had also been, in the first couple of months, in 2014, the last half of the year, in those first couple months [of the outbreak], along with this real push to trying to organize--what do we need for infrastructure, what do we have to get in-country--there was also a very big push on just communication. What is Ebola? What is Ebola, how do we explain it, how do we educate people on it? Originally, there was beliefs that Ebola wasn't real, that Ebola was manmade, that Ebola was 00:35:00from witchcraft, Ebola was a spell. Those first communication efforts were really about trying to dispel those myths, and really explaining that Ebola is real, which is actually one of the key messages that Sierra Leone developed early on, and then walking people through what they could do to keep themselves safe. So, what are the prevention things? Hand-washing, not touching. Don't touch other people, don't shake hands, don't hug. If you can, don't sit close to somebody in public transportation, try to keep space between you. What are the symptoms of Ebola? A fever, a rash, diarrhea, vomiting. Really, this kind of mass communication approach, and then organizing communication systems so that there's radio shows that are talking about it, and text messaging that's going 00:36:00out, and organizing the journalists to train them to speak accurately and with one voice. The first couple months were really based on setting up this mass communication program that included training journalists and getting their technology in line with how to explain the messages and bring knowledge up and dispel the myths and have conversations.

That also included the very important piece of engaging the religious leaders. We put religious leaders on the radio all the time. We could not have gotten--we could not have ended Ebola had it not been for the religious leaders. The imams, and the pastors, and the priests. Them coming forward and saying that the best thing to do for your family is to seek help, and to get help, and to forgo some of our--the burial rituals and cultural practices that they had to do at the 00:37:00home if someone passed away, and saying it's okay to not do that, Ebola is bigger than this. Let the people take your family member away. And if they pass away, their body will be respected, don't worry. Like, you just have to trust the system. The first couple months was really focused on communications.

When I came in January, through the different KAP surveys that had been conducted in 2014 and early 2015--KAP surveys are knowledge, attitudes, and practices--it was pretty clear that knowledge was very high, and people had been trained really well to understand the different prevention messages. The question now was, why are we still getting infections? When I showed up in Sierra Leone and I heard this, I thought, this was HIV twenty years ago. They had the education. They knew how to prevent the spread of Ebola, and that's 00:38:00exactly where we were in the eighties and the nineties with HIV--well, more so the nineties with HIV. That's what I actually would say to deployers when they came out. If I knew they came from an HIV background, I said, "This is HIV twenty years ago." We've now got to move them from knowledge, which is what the communication was able to do, to changing their behavior. Then they would say, "How do we do that?" And I said, "I don't know, but that's what we have to do." Actually, I have to give credit, again, to Dr. Oliver Morgan. He's the one who pulled me aside as Health Promotion team lead and said, "We need to start adding a behavioral component to this." He said, "Can you do it?" I was like, "Yeah, we can set that up." Honestly, I didn't know what it was going to look like, but I knew how to do behavioral science. That first group I had with me, we sat in a room in the hotel that we were living [in], and we had flip-chart paper taped to 00:39:00the wall, and we literally said, "How do we build a rapid behavioral investigation program?" The first thing that we all agreed on was that it all starts with the epi.

At that point, CDC had really focused--again, the focus. "Focus, stay in your lane." [laughs] We were focused in three districts: we were in Kambia, which is in northern Sierra Leone, and Port Loko, which is kind of more in the central, and then Western [Area]. And Western is also where the capital city was, so a very dense urban area. That's where the majority of the CDC deployers worked, was in one of those three districts. We had to figure out, how do we set up a rapid behavioral investigation program? And we agreed that we would start with the epi. First thing anyone would do is go to the district and go talk to the 00:40:00epidemiologists and say, what does the data say? What are the deaths looking like? What's the scenario, what's the situation that happened around the death? What's the story you've already heard? Because when there was a death or an illness, there was already a lot of investigations that were happening. If there was a burial, if there was a death, then there was a burial team out there, they've heard a story. If there was someone sick in the home, contact tracers were visiting, they were hearing stories. If there were pregnant women there, there was additional care being brought to them, they were probably hearing different stories. So our first goal was, what do we already know about this situation? And is there a behavioral component that we could look into that could help explain either why that death happened in the home--because, at that point, there shouldn't have been deaths in the home any more. We had the 00:41:00capacity for them to go to a treatment center. It was the why. Why did the death happen in the home? Or, why has this household had four to five infections, and we can't stop the chain of transmission? Or, why were they afraid to call for help, and they waited until the person was too sick for us to really help them and potentially save their lives? That's basically what we started with. We said, start with the epi, the epi data, and then ask if there's a why question. We didn't know what--that "why" question was going to change every time. But that's what our new job was, was to untangle the why. Why did the death happen, why did the infection happen, why did they take too long to call 1-1-7? One-one-seven was kind of the equivalent to 9-1-1 here: they had a free phone call. We were a phone call away, and we had a lot of people who didn't, who were 00:42:00afraid to call. So that's what we did: we tried to understand, for each case that happened, why. Because at that point, we had infrastructure, they had knowledge. We had 1-1-7. There really wasn't an obvious reason why we were still getting infections, but we were still getting hundreds a day. That's what the Health Promotion Team turned into.

As we started to untangle some of these issues around barriers to behavior, that then helped us improve our communication. Whereas originally, there was a lot of work in communications, and then, once we added this behavioral component, we actually were able to develop this nice ebb and flow--because sometimes, over the course of 2015, when I was there, there were periods of time when the 00:43:00behavioral science really was taking the lead on the team. Then there were times where the communications was really taking the lead. Then we would find out another piece of information, and then we'd have to go dig back into that from a behavioral science perspective. Then we would figure something out. Then we could start another, we could loop that back into improved communications messaging, and we'd get that on the radio and develop information materials on that, or incorporate that into trainings.

During 2015, what Health Promotions really became in Sierra Leone was this mix where, based on the epi data, we would investigate the why, and then take that information to directly impact something. Either a change in communication, or a change in a policy, or a change in the way that somebody was doing something. It 00:44:00was very case-by-case. But we did it at the district level, and it was just unraveling little knots. Every day was a different knot and that's what we would work on. Sometimes it was related to traditional healers, sometimes it was related to ambulances, sometimes it was related to confusion around what 1-1-7 really was. We never knew what it was. It's hard to say, what did Health Promotion do? We investigated the why and tried to then change a policy or communication that directly linked back to that.

Q: Can you break down, then, one of the whys? Why someone wasn't calling for help, and how you learned about that, and what you did with it?

HAGEMAN: Yeah. Lots of examples. One of them? So, 1-1-7. There was a lot of confusion about 1-1-7. People thought, if you called 1-1-7, it was basically a 00:45:00direct line to your loved one getting taken away. That's how they had believed that they saw it happen. But really, what 1-1-7 does, is it calls for help. You call 1-1-7, a person would call 1-1-7, and then the message would get relayed to the district level, who would send out a district surveillance officer to assess the situation. If the situation did not warrant escalation, then nothing happened. When the district surveillance officer did go to the home, if he or she felt that the person was symptomatic for Ebola, then that person could escalate it and call for an ambulance. So, really, 1-1-7 was ultimately more of a triage mechanism. It was, if you're sick for any reason, just call us. Let 00:46:00someone come out and look at you. And the other benefit of people calling 1-1-7 is that even if they weren't symptomatic that day, it would get that family, or that household, on the response's radar. Then maybe they come back, maybe they weren't fully symptomatic that day, but they would have someone come check on them a couple days later. Because sometimes that's what happened. The first time they came out, they weren't quite symptomatic. Then they checked on them the next day, or two days later, okay. We really think these are symptoms of Ebola now, and we would like to call for an ambulance and we'd like to get you help.

But I think what happened is that people were seeing--especially in the early days, people would wait so long to call 1-1-7 that by the time that district surveillance officer got out there, the person was very sick from Ebola. So the call was always, we have to bring an ambulance. People were really associating, 00:47:00if you call 1-1-7, the ambulance is going to come and take your loved one away. Then, because they were waiting for so long for them to get help for their loved one, even though we got them into an Ebola treatment center, they would still pass away. So what it looked like was you call 1-1-7, an ambulance comes, takes away your loved one, and then they die. And they had to have a safe burial, which meant that the family, loved ones, never got the body back. So 1-1-7 meant that your loved one got taken away, died, and you never saw your loved one again. Calling 1-1-7 was a really big ask, and it took us a really long time to understand that something that is so simple for us to say, "Call 1-1-7," had been extrapolated into these really complex--and each step being a massive life decision that's being made for the family.

Once we realized the complexity of how they were conceptualizing 1-1-7, we did a lot of work with community mobilizers and communication to try to explain that 1-1-7 is a triage mechanism, that's all it is. We're just here to see if you're okay. If you're not okay, then we have ways that we can help you. But at least call, and let us come look at you. That's all we want to do.

Q: How did you learn that that's how people thought about 9--what was it? Nine-one-seven?

HAGEMAN: One-one-seven.

Q: One-one-seven, sorry. How did you know? Were you doing interviews out in the streets, or what do you--

HAGEMAN: What we would do is, like I said, we always started with the epi data, and talking with the epidemiologist, and they would explain to us, what does the data look like, and what are the recent cases? And then, together, we'd come up with--the team members in the district would decide, "This one definitely has 00:49:00some type of behavioral thing. Go figure it out." So we would go to the quarant--the homes would still be in quarantine, and our team members, the Health Promotion Team members, would go and they would try--before they would go to the homes, they would try to talk with anyone else who had already been to the homes. Because as I mentioned before, the response team was quite big. You have burial team members, you have swabbers, you have contact tracers, you have medical officers. The houses get a lot of visitors to support them in the response. So what we first try to do is, go talk to who's already been at this house. "What have you heard? What complaints have you heard, what stories have you heard, what myths have you heard?" So that we weren't just going in cold. Then, based upon what they heard, they just started asking questions. Like I say, it's behavioral science. We didn't know what we were looking for, but we had to figure out, what was that home's challenge?

Over time, there were real, consistent themes that we heard. Fears around 1-1-7, and then, okay, well, why? "What scares you? Tell me what you think 1-1-7 is." It's this qualitative interviewing. Sometimes--and we would try everything. Talk to the family together, talk to the wife, or talk to the mother, talk to the primary caregiver, talk to the head of household, and everyone may have a different story, but there would sometimes be themes that would come out, that you would try to figure out, okay, this is probably what happened, this is probably the sequence of events that took place, this was probably the decision-making that happened, this was probably the way the conversations happened in the home. Because in these homes, they had these conversations. 00:51:00"Should we call for 1-1-7? Should we call for help? Is this Ebola? Should we move our loved one from this area to this area?" And if you move them, then you're, at that point, potentially spreading the infection. We knew all these conversations were had in every home, and that's ultimately what we tried to disentangle. "Tell us about the decision-making, tell us about the conversations."

Q: Were people pretty forthcoming?

HAGEMAN: It depended, it really depended. Sometimes you could find somebody right away who was just very open and said, "This is what happened." They had some people that were very afraid--especially if they had seen a lot of people get taken away and then subsequently passed away--were very afraid to talk because they were fearful that if they said anything, somehow that would mean 00:52:00that another family member would be taken away. There was some real confusion around this concept of being taken away, and not really correlating that with, we can help you.

We also ended up in villages that didn't know that there were survivors. They didn't know. Even mid-2015. Almost a year into the response. The first case was May 25th, 2014. We had villages a year in, who--when we would go out there and ask them questions--didn't know you could survive Ebola because they had never seen a survivor. Again, you think about asking them to call 1-1-7. Well, why would they? Because they didn't know you could survive from Ebola. They may have heard it on the radio, but if you don't see someone walk back into your village after having been taken away, it doesn't--you don't really survive Ebola. So it 00:53:00was these qualitative interviews to try to figure out what happened. We just asked, and asked, and asked. And redirecting is, for people who know qualitative interviewing, we redirected, and we asked from a different angle, and a different scenario, and different wording, and then we asked different people. It's the art of qualitative interviewing, just keep asking and redirecting, and hopefully you'll stumble upon something that sticks in your head, and you think, this was it. This is it, and now I've got to untangle that. So it was 1-1-7, it was fears around ambulances, it was confusion about what to do. Even a year into the response, people were still unclear, when they're quarantined, what they should do if a person got sick.

As we started untangling these, we were able to set up interventions--these little, small, programmatic interventions, to help get people to call 1-1-7, to 00:54:00get people to trust ambulances, to get people to understand what they should do in the home if they're quarantined, and if someone becomes sick, how to handle that. Because a lot of infections were happening within quarantined homes. They were passing the infections to each other, and we couldn't break those chains of transmission. We started really digging into, "Tell me what happens in your home. Literally. Who was the first person who woke up today? What did they do? What did the touch? Who did they touch? Who makes the food? Who gets the water?" And we started realizing that, after all this education and knowledge, when they were quarantined, they--rules don't apply when you're in your house. You do, you touch, and you hug, and you share glasses and plates, and all these things that 00:55:00they knew not to do when they were in the community. We started understanding the challenges and the misconceptions they had in the home. So then, again, that was another way that we could then structure a program to explain, and literally give them training of how to be in quarantine safely. Like I said, we never knew what we were going to find, and we didn't know how we were going to solve it once we found it, but we just figured it out.

Q: Were you the one doing a lot of the interviewing?

HAGEMAN: I unfortunately couldn't because I was in a team lead position. But what would happen was, as we were setting up the behavioral response, I would have the team [members] come in every week. Because things were changing so quickly, and we were trying to develop and systematize and standardize this approach, that the team members, the Health Promotion Team members came in every week, every weekend. We would spend Saturday debriefing. "What are you coming 00:56:00across? What technique did you use? What were the barriers you've already heard?" Because one thing we noticed is that, if we heard it in one district, inevitably the problem was also present in other districts, and then we could just translate. We didn't have to reinvent the wheel in every district. Then we could start sharing, "Okay, this was a problem that we found in this district. This is the way we proposed--this is what we tried to fix it. Hey, it worked. If you guys want to try it in your districts, here's everything we developed, here's all the training materials, here's the graphics, here's how we did it." We tried to do a lot of crowdsourcing, I guess. I didn't know, I wouldn't have thought of it at that point, but it was a brain trust. It was collective, and we had to build upon each other's knowledge of what they were learning in these qualitative interviews. When they would get stuck, we would motivate them to, say, go back again and redirect. There is something. There is something there 00:57:00that we have to understand, because that house has lost ten people, and we can't lose another ten.

Q: Are you thinking of one in particular?

HAGEMAN: There is this one story, where--it was relayed to me, I wasn't there, but--[pause] It was a family in quarantine, and they had lost quite a few people. The next one that had shown symptoms was this small baby. And the baby was crying. The family didn't want to give the baby up. I know our person worked really hard, but they couldn't convince them to give the baby up, and the baby passed away. That's really hard because that's about health-seeking behavior. 00:58:00That family had already lost so many people, and they knew this baby was going to die if they didn't hand the baby over. And they just couldn't do it. [pause] That's hard because we know what to do, we may have been able to save that baby. But they were so afraid of Ebola, and they were so afraid of the response. They couldn't trust us all the time. Just because they had seen so many people die. It was hard. But then we would have great families. No, not great families, but families that we really felt like, when they showed symptoms, they identified 00:59:00themselves, and they would get care, and then you could--they would come back. The survivors would come back after two, three months. And it was a big deal. But it was hard.

Q: In that particular case, was the person who was working with that family--were you the lead for that person?

HAGEMAN: I was, yeah. She was a member in my team. It was interesting because she had to work with the family, but it also turned into this issue where the larger response was getting very desperate to get this child. The response was actually starting to try to overpower the family. Not physically, but overpowering them to try to convince them to give them the baby. Also managing that, from having this behavioral science perspective of having someone come in 01:00:00and take that baby away, literally out of their parents' arms, was not going to help the response either. We didn't have a win in that scenario. Physically, forcibly removing the child wouldn't have worked. The child may have lived, but it wouldn't have helped the response. It wouldn't have helped that community. If the child stayed, the child was going to die. There were real levels of how you manage this. It's not just the family, but it's also how the response responds in those moments of crisis, and how do you just accept, sometimes. We tried to get religious leaders there to talk with them. You try everything. [laughs] You play every card you have. We tried religious leaders, we tried the chief. But 01:01:00when you're scared, you're scared. And that's what Ebola was, Ebola was just really scary.

Q: Did you have to do a lot of work--I know you were very focused, always, but--

HAGEMAN: Stay in the lane.

Q: Yeah, staying in the lane, but on maintaining the morale, the resiliency of your team members?

HAGEMAN: No. They were amazing. [pause] I think when you signed up to deploy for Ebola, you knew you were getting into something that was bigger than you. And 01:02:00you also knew that you were getting into something that was the reason why you went to school. Prior to Ebola, we haven't really had an outbreak that facilitated, to this magnitude, why you went to school. And this was it. This is why you go to public health school. It's such a simple statement, but this is why you go to public health school, is to be able to lend yourself to this type of an outbreak or public health emergency. You go knowing that it's going to be hard, but it's once in a lifetime. People were--the deployers were outstanding. 01:03:00We worked sixteen, eighteen-hour days every day. No questions asked, no one asked for a day off, no one asked to end early, no one complained. You were there to end Ebola. People didn't get, I don't think--when I think about my team members, I don't think they got frustrated trying to untangle--because it was a tangible thing that they were working on. Although it seemed intangible, they had a focus. They may have been frustrated because they couldn't get the information they needed, or they were having conversations that were going in circles, or there may have just been these roadblocks, but I don't think, at the end of the day, you--yeah. The calling was just so much bigger than a 01:04:00nine-to-five job. You were there to end an outbreak.

Q: But at the same time, people have these--have to maintain the mental health, right?

HAGEMAN: Yeah. [laughs]

Q: And there's that aspect of support.

HAGEMAN: Yeah. I think that's where--you know, people stayed--there were so few places of accommodation in these districts. Usually, all the responders stayed at the same hotel, or one or two hotels. Every day, everyone who stayed at the hotel had just lived that same day. I think that breakfast and dinner was probably therapy. What happened today, what did you see, how did it feel, what 01:05:00were your frustrations. I don't think they were thinking of it that consciously, but I mean, that's what it was. Because you were also just sharing, you were debriefing. Because it was the only time of the day that you ever stopped. I think it was just this organic thing, where in talking with everyone else, and knowing that everyone else was going through it, I think that also really helped. Because everyone was working long hours, everybody was having the same emotions, everyone was being frustrated by the same scope of things, whatever that thing was, for the time, place that you were at. I think, in some ways, it was a very unique experience for those of us who went, but amongst those of us who went, we all had a very similar experience, and so that in itself was the 01:06:00therapy. Everyone was in it together, everyone was working long hours. We would try to take Sunday off, as much as we could. That was our mental health day. It was very well-supported, but even a lot of times on Sundays you couldn't take the whole day off. It was just, it was being in the fire, but you weren't the only one, and so somehow it worked.

Q: If you had a few minutes, what were you doing?

HAGEMAN: What I would do? [laughs] I would go to my room and be alone. Some people would go out into nature, some people would go for a walk. For me, I think, I was always around people, and for me, if I could get a minute alone, I 01:07:00would just revel in that. I would be the one that would be up in the room. I'd be like, okay, I don't have anything for the next hour, I'm just going to stay in my room. Yeah. But I think everyone recharged in different ways.

Q: I want to hear about the ambulances. [laughter] Because I heard you talk about this just earlier, really brilliantly and vividly.

HAGEMAN: Okay. As we started doing these behavioral investigations, we understood that--we began to understand that there was a lot more around ambulances than we understood. Very similar to 1-1-7. Whereas we think of ambulances as a good thing, and the ambulances save you, and you would welcome the sight of an ambulance, we realized that ultimately was not how ambulances were being perceived. Again, at that crux of January, February, capacity was 01:08:00building up, and there were enough ambulances--or getting to be more ambulances so they could actually handle the amount of calls they got from 1-1-7--we were realizing that there was a lot of resistance to the ambulance. Part of that came out in trying to understand why people didn't call 1-1-7. People would say to us that they were afraid of the ambulances, or the ambulances were bad, or the ambulances killed you. And we thought, wow, that's a really different perception of ambulances than what we have. So we started doing a lot of work of trying to understand, what's happening around ambulances, and why do people not trust ambulances and want to ride in them? Through, again, qualitative interviews, and using behavioral investigation methods, we found out that ambulances were really 01:09:00complex. As I mentioned earlier, a lot of people saw their loved ones get in an ambulance and get taken away and then die. And not really clear, not fully understanding that their loved one died because they had a severe case, or an advanced case of Ebola, and they'd been sick for many, many days, so even though we got them to an Ebola treatment center, we couldn't save them. But that wasn't the part that resonated with them. What resonated with them was the last time they saw their family member. The last time they saw their family member was being put into an ambulance. So it was the ambulance that was the problem, it was the ambulance that was killing them, it was the ambulance that took their loved one away.

When we started looking more into that, we realized that them not having had 01:10:00previous exposures to an ambulance, the loud sounds and the noise and the lights, was very scary for them. The sound of that siren, being so loud in a quiet village, they didn't associate that sound with a positive sound. We associate that sound with help--they don't. The sound of the siren was very scary to them, the lights were very scary to them. They would tell us that, there was a word in the local language that sounded very much like the siren, that wa-wa, and that word in the local language actually means, "Bye." [pause] The way that the family members would conceptualize the moment was, their loved one was being put into an ambulance, and the ambulance was saying, "Bye." Then, 01:11:00a few days later, they'd find out their loved one died. So ambulances didn't have a good reputation. [laughs] There was a lot around the noise, the lights. There was also a lot of stigma around the ambulances because if an ambulance pulled up in front of your house with the lights and the sirens on, the whole community knew that someone at your house had Ebola. Or was suspected to have Ebola. Now, your house was now an Ebola house. Now, everyone in the community knew your house was an Ebola house. They also didn't want people, they didn't want that large of a spectacle outside of their house when their loved one was sick. So there's also this stigma around having the ambulance announce the fact 01:12:00that your house had become an Ebola house. They would call it, "I don't want to be an Ebola house, I don't want everyone to know that I live in an Ebola house." Things that we tried to do were educating the drivers to--request the drivers to turn off lights and sirens when they got close to the community that they were going to. They could use them on the roadways, but when they're traveling into the village they could shut them off, they didn't need to use the lights and the sirens anymore. They didn't need to use the sirens when they were leaving with the family member.

We also found out, as we talked more and more, and we tried to understand this concept of why you think the ambulance killed your loved one, was, they were also correlating the smell of the chlorine that the ambulances--that were used 01:13:00in the ambulance to disinfect the ambulance after each ride--with chlorine gas. Even for the ones that were willing to get close to an ambulance, or call an ambulance, they were overwhelmed by the smell of chlorine. Then the belief started that people were being put into the ambulance, and they were being killed by chlorine gas. They were being killed by that smell. When we realized that, we realized that it's more than just this fear of your loved one being put into this ambulance and being taken away and never seen again, but that they actually thought that the ambulance was killing them, that there was something in the ambulance, and that the driver was purposely choosing to kill their loved one. We learned a lot about ambulances.

One of the things that one of--a team member on Health Promotion came up with, 01:14:00Alisa Spieckerman, an amazing behavioral investigator, she really dug into this concept of the fear around the ambulance. Alisa realized that one of the ways to try to sensitize a community to being more accepting to ambulances, and understanding that ambulances are positive, and they can help you, was to develop this thing that we ended up calling The Ambulance Project, or The Ambulance Exhibit. It basically was taking an ambulance and identifying key response team members--so a nurse, a driver, a contact tracer, someone from the burial team, someone from the decontamination team--to go out with the ambulance to different villages, and go village-by-village, and call the village together 01:15:00and explain to them what the ambulance is. Let them touch the ambulance, let them crawl inside the ambulance, and let each response team member explain what their job was. The contact tracer would explain, "When I show up with the ambulance, this is what I'm doing." When a nurse or a doctor shows up, "This is what I'm doing." The driver says, "This is what I'm doing." And when she was kind of investigating what would really make this exhibit successful, things that she was told were that they had to be given the chance to actually get into the back of the ambulance and shut the door, and then have the doors open again to prove that you didn't die in the back of the ambulance. It was also really important that someone like a chief would get into the back of the ambulance, shut the door, open the door, the chief is still alive.

The first time they went out to do the ambulance exhibit, they had this program 01:16:00developed. We're going to have the driver explain the back of the ambulance, each of the response team members would explain what their job was, they would take questions, then the community could go and climb into the ambulance, they could touch the ambulance, and they had it all planned out. They did the exhibit, and then they were done, and then one of the questions that came was, "Where is the button that kills the people?" It took the entire team--and this was when they really started hearing about the button for the first time. Communities had really started to believe there was a button in the ambulance that someone would choose to push, and it would bring chlorine gas into the back of the ambulance, and it would kill your loved one. People kept asking about the button, "Show us where the button is." The other thing that clued them in is 01:17:00that people were not only interested in looking at the back of the ambulance, but they wanted to see the cab. They started asking about the button, and they said, "The button in the front." Spontaneously, they walked to the front, and the people were asking, "Which one of these buttons is the button that kills our loved ones?" And they had to explain that this is the same vehicle that each of you have, and that can drive. They went through, and they talked about what each of the buttons and the levers did in the front of the cab. And people would also ask, "Where's the hose? Where's the hose?" Because, again, they thought there was this chlorine gas that was pushed into the back. They looked, and they scoured, and slowly were able to be convinced that there was no button, and there was no hose. Then that gave us an opportunity to--it led us to our next 01:18:00area of investigation, was, we need to understand more about this, the chlorine concerns. What are your concerns around chlorine?

This shows the evolution of behavioral work. Because we start with something like 1-1-7, and in investigating why people were not using 1-1-7, we realized there was this issue around ambulances. And then, as we investigated the issue around the ambulances, we also then realized there was this issue around chlorine, that it's not just the ambulance but it's the physical smell of the chlorine used for decontamination. Then that gave us a chance to investigate and learn more about these fears around chlorine, and then talk through, what can we do to try to alleviate these fears, so that they understand the difference between chlorine for disinfecting versus chlorine that could kill somebody. That also was a really hard message because trying to explain the difference of this 01:19:00low concentration of chlorine that is strong enough to kill Ebola, but it's not strong enough to kill you, is a really hard concept to explain in a community, and in an environment, in which Ebola had been going on for--I mean, this was well into a year now. It was just into a year that we finally were able to get down to some of these key behavioral barriers that, early on, there just wasn't the capacity for. The focus was infrastructure, and beds, and PPE [personal protective equipment], and medicine, and high-level communication. We finally had been able to drill down to, okay, what are these remaining barriers? And realize there's lots of really fascinating things that, even a year into the response, real lightbulb moments we were having. Like, of course, oh my gosh, we can totally understand why in one moment we're asking them to use chlorine to 01:20:00disinfect and kill Ebola, and it hasn't been communicated well that, if it can kill Ebola, why can't it kill us? Because Ebola kills us. So why is this chlorine smell safe? Because everything else around chlorine kills Ebola. So we started finding these really fascinating ways that they were taking information very correctly, but then conceptualizing it in a way that we weren't aware of, that would then lead to a behavior that was impeding them to stay healthy, and disentangling that.

The ambulance exhibit took off, it was wonderful. By the time we ended and we finished the response at the end of December [2015], the ambulance exhibit had been rolled out, I think, in seven districts in Sierra Leone, and other NGOs had 01:21:00started doing it. We had trained up other--we wanted, from a capacity-building standpoint, to hand it off. We thought our success story around the ambulance exhibit was not that CDC continued to do it, but that NGOs and the district-level people would start to do the ambulance exhibit. Pretty soon, other people were starting to do the ambulance exhibit, and we hoped it helped. We don't--we never know what helps, but we would get big crowds, and people would ask questions that we never could have imagined if we hadn't literally showed up with an ambulance and given them an opportunity to ask us, and feel free to tell us some of these things. It's very different than just hearing on the radio over and over again, "Call the ambulance," or "Call 1-1-7." We were able to really drill down and disentangle some of these things that we didn't 01:22:00even know that we were fighting against. The ambulance exhibit was a really good moment of showing how, when you take the time to listen and ask those "why" questions, we realized that there was a whole 'nother underlying story to this response that we didn't know about. And until we addressed some of those issues, having this high-level capacity of infrastructure and drugs, we were at a disconnect. We had to put those two, the infrastructure and the behavior, together to wrap this up. It was a really good moment, I think, for everyone who ever participated in the ambulance exhibit.

Q: I want to get a picture of the arc of your experience, then, through the year. [laughter] How does it change from January to May, and then in the latter 01:23:00part, what kinds of different things are you working on?

HAGEMAN: In January of 2015, we were still very much at a high-level communication strategy and high-level messaging that was very nationally-based. We hadn't really dug into the behavior piece, where we were systematically investigating cases with the intention to untangle the case to come up with some action step, whether that was an intervention at the family or household level, some type of policy change in the response, or some kind of communication change. Then I would say February, March, and April was more of where we started digging down into the behavioral side, and realizing, slowly, that there was this whole undercurrent of information that we weren't aware of. Then trying to figure out, okay, now how do we make an action step out of that? Because from a 01:24:00public health standpoint, data is great, but if you don't use the data, there wasn't a lot of point to the data. We really pushed to be like, okay, once we've found this out, what is the action step, what can we change to improve the response? I think that's where, from the communication standpoint, it also got really interesting. Because I think up until that point, it was at a very national level and the communication messages were coming down. As we started doing the behavioral investigations, we were able to then say, very nuanced, either at the district level or within smaller sub-populations, this is the type of messaging we need to create for them. And we could do targeted messaging, either within the district, or we could target specifically for religious leaders, or for quarantined homes. We could be much more nuanced in how we 01:25:00leveraged the communication messaging that we were then developing from the district up. Then the stuff that was cross-cutting, we would then basically send all the way up, back to the national level, which then would get pushed down nation-wide again. Through radio channels, and through the Ebola Big Idea of the Week, which was this synthesized messaging that had happened early in the response, in which the journalism, media, radio, print, as well as the response infrastructure itself, all agreed that, to focus the messaging, they would go with one Ebola idea of the week.

Instead of every DJ [disc jockey] on the radio, every news article, every responder, and every social mobilizer and community leader picking a different topic to discuss on that day, or in that moment, very early on, Jenni [Jennifer 01:26:00H.] McQuiston, who was part of CDC, came up with this idea of, we just need a big idea of the week. Hence, it became the Ebola Big Idea of the Week, which we kept going for the entire response. We had that all the way through to the very end of [2015], and it just kind of coalesced. We developed a one-pager, of which it was the high talking points, and then the key messages, and then any prevention steps. Every week, we put out a new Ebola Big Idea of the Week. As we got more into behavioral work, we were able to do targeted messaging and nuanced messaging, and then when we came across some messages that needed to be more at the national level, we would incorporate them back into the Ebola Big Idea of the Week, which then would get national distribution. It would get picked up by the radios, it would get picked up by print journalists, it would get picked up in the president's speech. Many, many times, the Ebola Big Idea was mentioned in 01:27:00the speech that the president was giving, or the leader of the Ebola response, the in-country director of the Ebola response. I think, as we moved through and were able to incorporate more of these findings from the behavioral work, it not only informed and improved our district-level communication, but also our national-level communication.

Then, we hit this period in May, June, where we thought we were really close. We thought we were really close. And so we started shifting, thinking, how do we start preparing people for recovery? Unfortunately, we weren't as close to the end as we thought we were. It got delayed for a few more months. But it put that into our head, that as we get down to so few cases--one a day, then maybe not 01:28:00even one a day--what do we do? What are we asking the people to do? Because for fifteen months, they were given very strict rules from the government. Don't touch, don't have weddings, don't have large gatherings. Stores were closed, there was a curfew imposed. So, what's going to happen, what do we do? And how do we language that? From a public health perspective, what our focus was, everyone's focus was, was that the behaviors that we were able to instill for Ebola are important behaviors for just good public health. Washing hands, health-seeking behavior, trusting in the healthcare service, being willing to use an ambulance that originally had been used for Ebola. Feeling comfortable 01:29:00riding in that ambulance now, after Ebola was done. If you are sick, now the country has ambulances that can be used for general services. And helping people make that transition of, now we have all of this infrastructure, and it's good, and now we need to transition this to general health services. But do they have the trust in that? If they were too scared to ride in the ambulance during Ebola, we were very fearful that, once Ebola was gone, they still won't want to ride in the ambulance. Then, we started shifting towards, how do we start preparing them for recovery? Which is kind of the phase that was deemed post-response, at the international level, was recovery. You're in response mode, and then you're in recovery mode.

About August, September, we started thinking, we want them to continue their 01:30:00behaviors. We still have fear instilled in seeking help, fear around health-seeking behaviors, and what's going to happen the day that Ebola is--the outbreak is over? Literally, what was going to happen? We actually shifted our behavioral investigations towards that question. We started asking people, what are the behaviors that you think you'll continue? What are the behaviors that you liked, what are the behaviors you didn't like? What behaviors do you think would help for other things, like diarrhea and cholera, typhoid? Would you feel comfortable going to a healthcare facility? Would you feel comfortable riding in an ambulance? And we started trying to put together where they were, in willing to move beyond Ebola. A lot of people would say, when Ebola's done, we can go 01:31:00back, we can go back to normal. And from a public health perspective, it was never going to be normal again. They were never going to be able to go back to what it was. Because there's probably going to be Ebola in that area for a continued period of time now. We've seen that in Uganda, we've seen that in Congo. Ebola's not going to go away and stay away. There is a need for them to continue these preventative behaviors; there's a need for them to trust healthcare services; there's a need for them to not go back to normal. But people kept telling us, over and over again, "When Ebola's gone, we can just go back to normal." Then, the communication focus was--and it being driven by the behavioral investigations--how do we repurpose "normal" into the thinking of a "new normal?" How do we get them to believe in a new normal, and then how do we 01:32:00get them to continue this behavior in a new normal? That was hard because their lives have been put on hold for fifteen months, and for everything that happened, all they wanted to do was just go back to normal. They just wanted to go back to normal. We couldn't say to them, "It's never going to be normal again." [laughs] But we had to work through communication strategies and through behavior change efforts to try to get them to move in a direction of a new normal without saying that, because that would be resistance. Because they don't want a new normal. They've had this experience for fifteen months, and all they want to do is get back to normal. They want the kids back in school, they want to be able to harvest their crops again, they want to be able to plant their crops again. These were all things that they couldn't do when their house, or their village, was in quarantine. They wanted to have children again, and they 01:33:00wanted to have weddings again, and they wanted to have family gatherings again. They just wanted it to be normal again, and they kept saying that, over and over again.

The beginning of the year, it was about trying to untangle transmission chains. And at the end of the year, it was trying to get them to buy into, there's a new normal. And the best thing for the country is to try to continue with the adoption of these behaviors that you've already done: the hand-washing, the reporting of symptoms, any symptom. It's not just Ebola symptoms, it's cholera symptoms, it's typhoid symptoms, it's measles, it's continuing to call upon--the willingness to call for help and to use healthcare services, and to still be part of this larger response that the entire country kind of had to accept, but moving forward instead of moving back. They really just wanted to move back. So 01:34:00that was kind of the big shift. Again, when we moved into that phase of, well, what do we do now, and how do we prepare them? It was, in some ways, the same feeling of starting over that we had in January, when we started with the flip charts stuck to the wall, of how do we build a behavioral investigation to untangle transmission chains? But it always would come back to the foundation of behavioral science. Trying to understand, what are they feeling today? What are your challenges? What are your barriers? What don't you like? Eventually, you would pick up on perceptions and myths about the response that we knew were going to impede them, moving forward, and so we knew how we could target communication strategies, or try to get community involvement to try to get them to buy into this unspoken idea of there's a new normal in town.

That's what we did. That's how we closed up shop. Not that Ebola's done, because 01:35:00Ebola's not done, but trying to prepare them for this new normal. I think that's--I left at the end of December 2015, and I haven't been back, so I don't know how that transition plan has happened. But it's the new normal now, and that's what the country is trying to set up, and that's what all the agencies and organizations are trying to figure out. How do we get the behaviors that they were doing to continue? And how can we still address some of these barriers that they had, around ambulances and fear around healthcare, so that when there is no Ebola, they will still seek help? And then, when Ebola comes back, which it has already done a few times in Sierra Leone, that they're not afraid of the response, that they're okay with us standing up again. It's a lot. There's a lot 01:36:00of things that it's going to take time: to rebuild trust, and have them feel safe, that this new normal is going to work.

Q: Is there one method of trying to instill this idea of the new normal that you look back on as, this was really important?

HAGEMAN: Can you repeat the question? [laughs]

Q: Sure, yeah. You're trying to spread the idea that it's a new normal, but a way in which you spread it.

HAGEMAN: Right. One of the things we did, towards the end, is that we did a radio serial drama. We wanted to focus on--actually, just from a public health perspective, what we originally thought we were going to use for the radio serial drama topic--because the response changed so quickly, we actually timed 01:37:00out of the importance of the first topic we picked. Which I think is just the way the response was. Things changed so quickly. Things could change daily, let alone a week or let alone a month. When we first came up, had the opportunity to engage in the development of a radio serial drama, we thought, great, we'll have this topic, and it will be wonderful. And even in the three--in the few weeks that it took to get it up and running, the response had changed, and we had gotten much closer to zero, and we realized that we really need to focus on this new normal. We actually called the radio drama "The Road to Recovery." We tried to focus on reworking some of the remaining beliefs and myths that were still 01:38:00out there, around use of the ambulance, that Ebola's not going to be gone. Ebola, this outbreak may be finished, but Ebola's not gone. And really trying to explain that to them through different characters who would keep saying, over and over again, "When Ebola's gone, we can go back to normal." And we would tell them, we would give the information that we had learned through--the language, the way that people would language it, we would give it to them, and they would incorporate that into the scripts. There was a lot of conversation in characters who just wanted to go back to normal, and someone saying, "But it will never go back to normal. We now have Ebola here. The outbreak is over, but Ebola is not finished." Then going through and reworking why it's important to continue with these behaviors, because of other health benefits, such as cholera and typhoid. The behaviors that we started with Ebola will also help reduce transmission and 01:39:00infections with these other diseases.

We also spent a lot of time with that one, "Road to Recovery," of talking about survivors. Because there, at that point, towards the end, I believe we had over three thousand survivors in Sierra Leone. And as much work as there was to destigmatize them--and we would think, from our perspective, you're an Ebola survivor, you're going to be a hero, you're going to be worshipped. You've gone through this horrific, body-wrenching illness, in which you can't even imagine what your organs, and your body, was doing, and you were able to come out and survive. But they weren't always welcomed with open arms back in the community, because the community didn't understand that they were safe, that they couldn't spread Ebola, that they weren't a risk to them. So there were still a lot of 01:40:00concerns around integrating survivors into families. It was not uncommon for survivors to be chased from homes, to be chased from schools, to lose jobs. Even, we heard of healthcare workers who even lost their job after they survived Ebola because even in the healthcare facility arena of medical professionals, there was still this concern about having an Ebola survivor, either out of risk of transmission, or--there was f--things that we heard in the interviews, was that clinics didn't want an Ebola survivor working there, because they were worried that it would bring a bad image to the clinic. "Well, that clinic has an Ebola survivor in it, so that clinic's not safe to go to now." There was lots of stuff around trying to support survivors and destigmatize them and encourage them to be re-integrated into the community. Although a lot of work, progress 01:41:00had been made throughout the course of the year, there was still these underlying concerns and things that we would hear of people not wanting survivors to come back into the household, or they couldn't get employment. Kind of survivor discrimination stuff.

"The Road to Recovery" also included a lot of work around, what is your life looking--what does it look like now, to have a country of three thousand survivors in it? How do we integrate them, and how do we empower them? They're no different than the rest of us. So that was also a piece that we really rolled into "The Road to Recovery," and the new normal. Because it is their new normal now, they will have lots of Ebola survivors for the next twenty, thirty, forty years. Hopefully, over time, they'll be more accepted.

Q: I'm a little curious--can you tell me about the couple months when you were away? Did you go back to Atlanta?

HAGEMAN: I did. I came back in the middle. I went to Sierra Leone, January to 01:42:00the end of May, and then I was in Atlanta June and July, and then I went, returned to Sierra Leone, August through the end of December.

Q: What were those months like, when you were back here?

HAGEMAN: Weird. We had been prepped pretty well from other people that had come home during that really intense time, that it took about a month to really get your head wrapped around just day-to-day life. I had thought, well, I'm really well-traveled. I've lived in India, I've lived in the Middle East, I've lived in Southeast Asia, I've lived all over Africa. I'm good. [laughs] And you are good, 01:43:00in the sense that you can get out of bed, and you can return to your job at CDC. But you're not fully back. Partly because I think the level of exhaustion and stress--people would describe it as brain fog. Even when I was in it, I didn't realize I had it until I was coming out of it. Then it probably took me about a month, too. It was exactly what everyone told you. The first month, it's going to feel like you can't get your head wrapped around--you know, like you're moving through the day, and you're driving yourself to work, and you're getting showered, and you're making food. And from the outside it looks like you're completely functioning. But there's this brain fog. And it wasn't until I was coming out of the brain fog that I realized, wow. I really hadn't--I'd been only engaged at a very superficial level, the bare minimum of kind of--like, that 01:44:00survival mode of get to work and eat and shower.

The other thing that was really different was that when you were there, if someone talked to you or someone called you, it was an emergency. [When back in Atlanta,] I would have friends call me on the phone, and my response would be, "What do you need?" And they would say, "We're just calling to talk." And I'm like--and I knew I wasn't in a crisis mode any more, but I would say, "But what are you calling me for?" And they would be like, "We're just calling to talk." And I go, "Okay, well, I don't have time for that." And I would hang--I would essentially hang up on people, in a nice way, because I couldn't--it was so intense [in Sierra Leone], that if--especially if the phone rang, something was not good. Because we lived on our BlackBerrys [over there]. Really it was just keeping up, in real time, which was real time. If we had a meeting, a decision 01:45:00would be made, and something was implemented by the end of the day. We were working at such real time, on BlackBerrys and in meetings, that if there was a phone call, or if someone needed to see you, you knew something bad had happened. So when people--when that would happen here, I couldn't turn it off. To the point where I even knew I was doing it. [laughs] And I couldn't understand how they could have time. How can you have time just to talk to me? Because if you're talking to me, there's got to be a problem, and there's not time for just general conversation. That was also part of that brain fog, of trying to come down from a situation where it was really high-stress, you weren't sleeping, you were maybe sleeping five to six hours a day, you were working seven days a week, you were hyper-focused to the point where you didn't have extra conversations--unless it was kind of pre-negotiated, like, "I'm going 01:46:00to go have food," and then someone would say, "Oh, I'll go have food, too." And then it was like, okay, I know we're now having food together and we're relaxing. [laughter] You kind of were pre-negotiating things, subconsciously or quietly. But I think that was--that's what we were coming back with. And especially for the deployers that were there for thirty or forty-five days, they came knowing, you're going to be on all the time, that's why you're there, you're there to be on all the time. It was being thrown into the fire. It took a while to come down from it. And right when I was coming down from it, and I was having social relationships again, I got back on a plane and went right back into it. [laughter] Yeah.

But the other good thing about, if there is--I don't want to say that there's good things about an Ebola outbreak, but there is such a community now, of 01:47:00where, if you see somebody that you worked with, you've been through the fire together. [laughs] There is now a community of people who understand.

Q: Can you talk about some of the people who you worked with most closely, and--I don't now, any memories of working with those people that really stand out to you?

HAGEMAN: Oh, gosh. I would say the strongest memory--and Oliver doesn't even know this--my strongest memory is Oliver. Just being so hyper-focused, and kind of like coming in front of the judge. Because he was just so focused on, how does it get us to zero? How does it get us to zero? We would have meetings three--Monday, Wednesday, Friday, there was kind of a senior staff meeting at seven thirty every morning. Everyone that was considered senior staff would sit 01:48:00around this very big table, because there was--and there was probably thirty of us that were considered senior staff, when we had over one hundred deployers, twenty to thirty of us. We would each update him on what we were doing, our team was doing, our deliverables. It would be, we would say it, and in my memory--and maybe it wasn't really like this, but this is what it felt like, is--he would ask each one of us, around the table, after we told our update, "How does it get us to zero?" How does it get us to zero? And if we couldn't really enunciate how it could get us to zero, he would be like, "Then don't do it." Then the next meeting, you'd better have a better answer, and you'd better have a better idea. I have a very strong memory of Oliver being so hyper-focused, and just repeating, over and over again, that, "If it doesn't get us to zero, it's not CDC's mandate."

Then, I think, yeah. I have so many memories. We had amazing people that came 01:49:00out on the Health Promotion Team, who in blind trust and faith, believed that we could build this behavioral response when we didn't have a framework. We had the tools of what we'd been trained in, but no one had ever--no, we didn't know, there wasn't an article we could pull from the literature of how to stand up a behavioral response to be included into a larger epidemiological response. Just blind trust. We have to do this. We've got to untangle some of these questions, because we're--eventually, if we don't, we'll stop making progress, to some degree. Some real amazing team members, who just, every day, woke up, didn't 01:50:00know what challenge they were, what little question they were going to untangle, but they figured it out. Some amazing team members, like Alisa Spieckerman, who developed the ambulance exhibit, or Rashon Lane and Erin Burdette developed the quarantine safety plan, which was developed out of the fact that we couldn't figure out how to stop infections within quarantined homes. They were the ones that started, very basic, "Tell me what happens in a quarantined home. Who touches who, who eats from which dishes." They developed this lovely behavioral plan in which we worked with each quarantined home on how to set up their own safety plan. We called it, we "feng shui-ed" their home. [laughs] We would literally talk with them. "If someone gets sick, when the next person gets sick, 01:51:00where are they going to lay down? What mattress are you going to choose? Is that mattress already ready? What glass are you going to use? Okay, let's put the glass right next to the bed right now." So that they wouldn't have to make any decisions in the moment. "When someone gets sick, how are you going to notify somebody? Do you have a cell phone? If you don't have a cell phone, who has a cell phone? Does the neighbor have the cell phone? Can you yell to somebody to call"--so we literally, for every quarantined home, they developed this plan, through trial and error, of how do you walk them through every possible scenario so that when the next person gets sick, they had the plan. And they would agree upon the plan, the family members would sign the plan, and that was called the quarantine safety plan. Towards the very end of the response, when we started getting down to just a handful of cases, then we actually trained up social mobilizers to do the quarantine safety plan. At the end, when we would have hundreds of homes in quarantine because it was the last case and the whole 01:52:00village got put into quarantine, we would have thirty or forty social mobilizers going house to house, so that every quarantined home had the quarantine safety plan. That was developed from Rashon and Erin's work, behavioral work, which had been developed out of the ambulance work. Just some real amazing team members who took on the challenge and were able to figure out that really key action step, for what CDC could contribute to the response to truly try to break a transmission chain.

Then, of course, there were amazing people that worked at the ministry level, and as part of the Sierra Leone response, and us trying to train them up, sometimes, in communication strategies. In Sierra Leone, it was a military response. The Sierra Leone military ran the Ebola response, which is great when 01:53:00you need supplies delivered very quickly, and infrastructure set up very quickly, and systems put in place. But trying to work with them about communication strategy, and how do you language something so that it's empowering, instead of "don't." That was another big switch we made--and I should have brought it up when we were talking about the timeline of me being there--is, there was a lot of "don't" messaging really early on, because they were just trying to stop transmission. It was, don't touch, don't wash bodies, don't do your own burials, don't have weddings. That was a really important piece because they just had--I really do think that they had to get those key, very clear messages out, "These are the things that, if you do, infection can 01:54:00spread." So just don't do these, you know, the starter kit. Your starter kit was really a frantic, "Just don't do these," and we'll build on the kit after that. What we did around February, March, is we started rewriting all the key messages, and we took out the "don't." So, instead of saying, "Don't wash your loved one's body when they pass away," which was probably the biggest driver of the transmission of Ebola, and the washing of the body was tied with religious and cultural practices, we re-worded those messages to say, "Ways in which you can honor your loved one would be to do this, and to do this, and to do this, and to do this." So instead of just hearing a don't message, they heard an empowerment message.

We went through and we rewrote all of our key messages at that point. Which, at 01:55:00this point, we had gotten up to a document of probably thirty or forty pages of key messages that, with the Ministry [of Health and Sanitation] and with the response, and CDC, and some other key agencies and organizations, we'd developed this document, Consolidated Message Guide was what we called it, which was the clearance document. If it made it into the document, it had been approved. Along with this don't messaging, we basically rewrote a companion empowerment statement to each one of the don't messages, and we started focusing more on what they could do. What could you do to honor a loved one, instead of washing their body? Since you couldn't have a burial the way you traditionally have a burial, this is the way you can participate in the burial when the response is in charge of the burial, is providing the safe and dignified burial. Trying to 01:56:00change them, to understand that they are an active player in this, and they still had a really important role, and they felt empowered. A lot of people felt that, with the level of restrictions that were put on them, they were not empowered. We tried to re-language the key messages so that they could feel empowered. I think, through some of the communication team members I had, which also sat under Health Promotion, of us working through--our motto was, what--I forgot the motto. "No more don't," I think was our motto, "No more don't," or, "I don't want to hear"--I think it was, "I don't want to hear 'don't.'" And then, moving forward, we did no more messaging that included a don't message. It was all about empowering, and this is what you can do.

I remember communication team members that were part of Health Promotion that did that, and then working with the response in the military, and helping them understand the importance of communication strategies, and that don't messaging doesn't work if you're not in the military. [laughs] They were great, they were so open to understanding that things that may have worked in a very military environment, of do this and don't do that; when you translate that to a community, and to a nation, that's going to work for a very short period of time, which it did. It was a very important period of time to really get transmission under control. But at some point, that don't messaging is going to wear off. It's like talking to a kid--it works for a short amount of time, and then at some point they're going to be, they're going to feel like, I'm over it. And that's where we really felt like the importance of getting the response, the 01:58:00people at the response, in the ministry level who worked on the communications, to understand that the communication has to be evolving as well. As people get exhausted with the don't messaging, we have to move into empowerment messaging, which ultimately led into the "Road to Recovery" messaging. Because once someone gets saturated with the message, they stop hearing it. And helping them see that process. But we had amazing counterparts at the Ministry. Mr. [Lasana] Conteh was the person in charge of the Messaging Committee, which, if you can envision a very small room with probably forty or fifty people sitting around the edge of the room on benches, and there was no air conditioning, there were a few windows. We would sit in that room every Wednesday afternoon, and that was the messaging committee. We would debate and argue and defend what was the correct 01:59:00messaging so that it was culturally appropriate, it was scientifically sound, it was gender-neutral, it was ethnically neutral, it was positive, it didn't have a discriminatory or a stigma bias to it. That also, in going back to Oliver's ultimate focus of "get to zero," Mr. Conteh was, "We've got to get this messaging right." He understood it. He was actually in the health education sector of the Ministry of Health, so he understood that, if you get messaging wrong, it will hurt you for months. He really understood the importance. We would debate, and we would professionally argue and challenge each other, until we would get that messaging perfect. That was every Wednesday in a very hot, 02:00:00small room. But it was really good, because a lot of the agencies and organizations showed up. And if they showed up, it meant that they understood the importance of the messaging, because they were submitting their messaging for review as well. The idea was that anyone who was putting out messaging had to send it through the messaging committee, so there was a consistent voice, and it was cleared to be appropriate and ethical and scientific. Mr. Conteh was the driving force behind that. He did not want to mess up messaging. He was very committed.

Q: Looking back on that year that you were there, 2015, is there anything that we haven't talked about yet, that you'd like to talk about, make sure we have on the record for future researchers?

HAGEMAN: I think it really comes down to--and it's going to sound very biased. 02:01:00But the importance of behavioral science and communication in these outbreaks. It's very easy to think, send epidemiologists, send MDs [doctors], send logistics. But if you don't get communication right at the beginning, you will pay the price for a really long time. And something that came out in the very, very early months, we continued to hear at the very end. It was that very early, someone put out the messaging--not CDC, but somebody put out the messaging that there's no cure for Ebola. I think what they were trying to say was that there wasn't a pill, there's not a treatment. But what people heard that to mean was 02:02:00that if you get Ebola, you're going to die anyway. So why would you use the response? Why would you call for 1-1-7? If there's no cure, if you can't survive--what that translated to was, "You can't survive Ebola." So people didn't want to have their loved ones go get treatment, they didn't want to give their loved ones for safe burial, all these things that we knew would have prevented further transmissions. It was because one of those very first early messages that got put out was, there's no cure for Ebola. And even at the very end, when we were working on trying to create this idea of a new normal versus normal, people would say, why did you tell us that there was no cure? Because we spent a long time thinking that we couldn't survive Ebola. And that was fifteen months after that message went out.

I think it's just so important early on that, when you're thinking about, who 02:03:00are you going to--how are you going to set up your organization, your response teams, in addition to your epis and your MDs and your logistics and your infection prevention and control, the importance of communication and a behavioral scientist at the table at the very beginning. Because if you don't get communications right at the beginning, it takes so long to undo that damage. Behavioral science, then, finds all this underlying information that's driving the epidemic that you would never find out about unless you actually had someone digging down to try to understand the behaviors and the myths and the reasons why they're doing it. I just can't express enough, the importance of having those two groups at the table from day one, moving forward on outbreaks or 02:04:00epidemics like this. We saw it in HIV. We know the importance of behavioral science and communication in HIV, and something like Ebola was so much like HIV. And probably most outbreaks of really infectious--we know it, and we don't need to keep reinventing the wheel. I just think it should be part of the standard package that CDC, and all agencies, provide. Along with these other really technical areas, you include communications and behavioral sciences in that technical arena. You're in the first wave, and then you have constant deployers following up. The importance of keeping them at the table, and adjusting to the response--because we changed our communication strategy throughout the entire response, and we likewise changed our behavioral investigations throughout the 02:05:00response, and just the importance of those two fields included in this kind of work.

Q: I promise we're almost to the finish line here, but when we talked a little bit before we started recording, with Louise [E. Shaw], you also talked about the changing approach to traditional healers--

HAGEMAN: Oh, yes. [laughs]

Q: --and I'm wondering if you can talk a little bit more about that.

HAGEMAN: Sure. Traditional healers, if I can--got a bit of a bad rap. I think people don't understand the important role that traditional healers play in countries that don't have strong health facility infrastructure. In a lot of places--and it was evident in Sierra Leone--in areas where there's not clinics or hospitals, the community relies upon the traditional doctor, traditional 02:06:00healer, as their medical professional. Using herbs and plants and roots, they're able to relieve headache, they're able to relieve aches and pains, the same way that allopathic medicine can do. Now, granted, there are traditional healers that are of concern, but I would say there's also medical practitioners. They are not all of these witch doctors, and all these stereotypes that we hear about. Traditional healers are a really important piece of a lot of developing countries' health infrastructure. They are the ones that are the only person within walking distance that a community could get to if they have symptoms. They also are the ones that, largely, deliver children, if there's not a clinic nearby; they're the ones that will treat for malaria. They can't treat the malaria, but they can treat the symptoms of malaria using plants and roots. 02:07:00They're actually a really important part of culture, both from the medicinal help that they can offer when there's no other resources available, but there's also a trust that they instill, in their community, of them being able to help.

I think one of the restrictions that happened, during the early days of Ebola, along with no touching and no hand-shaking and no hugging and no weddings, was that no one could go to a traditional healer. If you broke any of these restrictions, the threat was--or the fine was, I think it was the equivalent to about a thousand US dollars, which no one would have. I asked informally, "Why was the fine so big?" And they said, "Well, we really want people to really not do this." They felt like, maybe the fine was so big because it would discourage 02:08:00people. But at the end of the day, what happened was, just with no preparation or plan for what to do with traditional healers, when that restriction was set in which no one could go to a traditional healer, and traditional healers weren't to treat any more, you removed this safety net of healthcare that was being provided at community levels where there weren't other facilities available, there was no other healthcare provided. Instead of engaging them in the response, which eventually happened later on, they were initially, from what I understood, just removed. Like, we're just not going to, we don't want you to go with them, we don't want people to seek care from them, and we don't want to engage them. And what we ended up trying to do more in 2015, is we kind of 02:09:00learned that we really need to engage them.

People were still going to go to traditional healers because they may have been the only person they could go to. Or they were choosing to go to, continue to go to traditional healers, even if there was a clinic that was walkable, because the trust may be stronger with the traditional healer than with the clinic. And, especially as concerns around the response built, and beliefs that 1-1-7 was going to take your family member away, and that the ambulance was going to kill you, some people weren't comfortable going to clinics to seek care. So there was an effort, over time, to engage the traditional healers and, one, make sure that they understood the realities of Ebola, that traditional medicine cannot cure Ebola. And, for the most part, of the traditional healers that we worked with through trainings--and it wasn't just CDC, but a lot of organizations were 02:10:00working with traditional healers--they were very responsive to the fact that they understood that they could not--for the most part, they were very responsive to the fact that Ebola was not something they could treat. They could treat the symptoms, they could treat the vomiting, they could treat the diarrhea, they can treat the headache, they could treat the rash, but they couldn't treat the actual Ebola, and it's the Ebola that was killing people. They were very open to that, and they wanted to be a part of the response.

I think, in moments when quick decisions have to happen, it was just easy to say, don't engage traditional healers. They didn't have access to PPE, they had no way of protecting themselves. They also didn't have any treatment that would actually help someone survive Ebola. So it makes sense, in the moment of crisis, to just--because they ultimately could lead to more infections, if they were treating people. It was sometimes very frustrating because they wanted to be a 02:11:00part of the response, and I think, if there was time--and we always said, during the response, "We just wish there was more time." One of the really good lessons learned was, we could have brought them in much earlier, and we could have given them distinct roles. In the sense of also helping them feel empowered--that when someone came to them, asking for help, that they had the language and the negotiation skills to encourage that person to come into the response. Although we would say, "You should just send them our way," I think there was more that we could have done, of how can we empower them? Because now, at that point, the community trusted them more. If they turned around and said, "I think you should really just call 1-1-7," then that's now disrupting the trust that they have with the community. I think we could have done more to try to understand, how 02:12:00could we have integrated them more so that we use them as a catalyst to help people get to us and get to the response? Helping them being able to do that, while maintaining the sense of trust in the community.

The other thing that was really hard, I think for them, is that when that restriction came, from that day forward they had no income. It would be as if one day, someone came into the company and said, "The company's done. No more salary, and no one's allowed to talk to you, no one's allowed to come visit you." We had traditional healers who--their income was gone, they didn't have a way to live anymore. They were, many times, highly respected in the community, but now had been disempowered by the way that the restriction had happened. A lot of them, because they are the only healthcare provider in their area, still 02:13:00felt the same obligation that a medical provider would feel: if someone is sick, I want to try to help them even if I can just help them with the symptoms. So throughout the response, we still had situations where traditional healers were within transmission chains. Someone had come to them, infected them, and then they went on and treated someone else and then infected that person. They were in there, people were coming to them for help, they were getting infected, and then they were helping other people and getting infected. It's hard. I think there's probably a lot more room, in retrospect, that we can think through, of, if this happens again in a community that is largely dependent on traditional healers as healthcare in rural areas, what is our plan, moving forward? How do we integrate them in a way that keeps them empowered, but also keeps them safe, 02:14:00so that they're not getting infected and they're not feeling obligated to then treat, and then thus infecting somebody else? It's something that, of all the things that we had to untangle, it wasn't something that we really had the time to figure out how to do that. We got them into some trainings, and we had them in to workshops, but I think there's a much more systematic role that they could have played, and we just didn't have the time, in the chaos and the crisis of making rapid decisions of breaking transmission chains, to really think through, what's a really integrated, supportive way that we can use the traditional healers, the same way that we use the religious leaders? I mentioned, before, the religious leaders. I think, really, we couldn't have put an end to Ebola if it hadn't been for them. If we could have figured out a similar way to integrate 02:15:00the traditional healers, between their sense, their dedication to still helping people, and the trust they had, we could have really used them as a catalyst to make greater headway into some of these communities that weren't used to Western medicine, clinical assessments, and an ambulance. In these rural areas, sometimes the only person they ever had sought care from was a traditional healer. To cut them off that way, I think, was very hard, both for the community, and then for the traditional healers. And, ultimately, for the response. So hopefully, moving forward, there will be some time to think through that in the future.

Q: Can you tell me what happens with you after the response?

HAGEMAN: [laughs] Yes. Two months after coming back from Sierra Leone, spending 02:16:00a year working on Ebola, I was packed up, and I moved to Zambia, which is in southern Africa. It was a bit frantic, to come off of a year of Ebola response and have two months to pack up my life and move it, but it was good. I am back working in global HIV, which is where I started years ago, and I'm now the branch chief for Epidemiology and Strategic Information in the CDC country office in Zambia. I miss Ebola, I miss Sierra Leone, I love getting sleep again. [laughter] I'm very happy to be able to have weekends again, but it is great when I bump into people I worked with.

Q: Anything else that you'd like to say for the interview?

HAGEMAN: No, I think that's good.

Q: Okay, this is quite comprehensive. Thank you so much for the time and energy 02:17:00you've put into this. This is going to be a really great resource.

HAGEMAN: Thanks for doing this for us.

Q: Of course.

END