Dr. Lyle Petersen

Dr. Lyle R. Petersen

Q: This is Sam Robson on the phone with Dr. Lyle Petersen. Today's date is July 9th, 2018. I'm in the audio recording studio at CDC's Roybal Campus in Atlanta, Georgia, and Dr. Petersen is on the line from Fort Collins, Colorado. This is my second interview with Dr. Petersen as part of the CDC Ebola Response Oral History project, following up on one that we did way back in 2016 when Dr. Petersen was incident managing CDC's Zika response. Dr. Petersen, thanks for joining me again after all this time. In our first interview, we talked about some of your initial work in Dallas moving operations to the Dallas [Texas Health] Presbyterian Hospital, working alongside Judge Clay Jenkins and others, Mayor Mike [Michael S.] Rawlings. Following up on that, I wanted to ask, one of the people I've gotten to interview through this project is Dr. David [T.] Kuhar. I'm wondering if you can describe a little bit what it was like working with him.

PETERSEN: Dr. Kuhar was certainly a very accomplished scientist, but a fairly 00:01:00junior person who had really not run a large operation like what was going on in Dallas at the time. Unfortunately, he was the subject matter expert in dealing with infection control in the hospital, but also trying to run the whole operation at the same time, which was pretty overwhelming. Overall, I found him to be a very personable person, very knowledgeable and fun to work with.

Q: I know it's been quite a while now, four years I guess--do you remember any interactions you had that were particularly congenial?

PETERSEN: I think when I came in, Dr. Kuhar had been running the operation there for some time, and I was a little afraid of coming in there and stepping on 00:02:00people's toes, just barging in and taking over. I was a little afraid of the personnel dynamics of the team, but those fears fortunately were unfounded. Dr. Kuhar was more than happy to have me take things over so he could get along with his work dealing with the patients themselves and hospital infection control there. He was also very valuable in helping to prepare the other hospitals in the area for additional Ebola patients if they should come.

Q: What was the balance like when you arrived on hospital infection control that CDC was focused on advising on, versus contact tracing in the community?

PETERSEN: There was both going on at the same time. There was certainly the 00:03:00infection control in the hospital and taking care of the two nurses--well, originally one nurse, and then the second nurse--but also there was an ever-expanding number of contacts that needed to be followed up in the community, which is a major task in itself. I can't remember the exact number, but there were well over a hundred contacts that needed to be followed up, and dealing with a number of health departments in the area. That was an overwhelming task in itself.

Q: I think in our first interview we got to the point at which we had discussed the nurses being transferred to the facility at NIH [National Institutes of Health] and Emory [University Hospital], and then I think I had asked you something that alluded to the number of weeks you were there, and you responded, 00:04:00"Actually, I was there over a period of months." What actually were you doing after that mid-October point, after the nurses had been transferred?

PETERSEN: After the nurses were transferred, things certainly calmed down at the hospital rather dramatically, of course, and a lot of the media attention went away. But there were still the issues of following all the contacts, dealing with a number of issues in the community such as that patients were coming from West Africa with fever, many of which had malaria or other illnesses that were completely unrelated to Ebola. The hospital staff were very afraid of taking care of these patients, fear of getting Ebola, even though the possibility that 00:05:00the patients had Ebola was rather remote. I dealt a lot with a number of hospitals around Texas, trying to allay fears and make sure those patients were adequately treated. The other issue was trying to prepare other hospitals in the area in case more Ebola patients should show up. We actually were able to make a second Ebola treatment unit in one of the other hospitals in the area in case more patients arrived.

Q: Does that mean that Dallas was remaining to be first--that patients might still be treated at the Dallas Presbyterian Hospital should they come in?

PETERSEN: Well, certainly the emphasis was on sending patients to established 00:06:00centers that could take care of Ebola patients such as in the National Institutes of Health and Emory University. However, the number of beds in those specialized units is rather limited, and one of the concerns was, what happens if ten patients show up all of a sudden or twenty patients show up all of a sudden? There wouldn't be adequate bed space to send these patients to these other established facilities. What was prepared in Dallas was clearly a backup measure.

Q: What kinds of things would you tell these clinics in the area to help allay concerns about these travelers coming in with potential symptoms that could be linked to Ebola?

PETERSEN: Well, one of the things that Dr. Kuhar had organized was training 00:07:00sessions for the staff, both at the Presbyterian Hospital but also for staff at other hospitals around the area. Of course, when people know what to expect, have knowledge of the syndrome, the fears tend to be less.

Q: I know it's been a while, but do you think it was 2015 by the time you left, or do you remember how long you were in Dallas overall?

PETERSEN: I simply don't remember. [laughter] It was certainly a while.

Q: Sure, sure. What happened next in your experience with the Ebola response at CDC?

PETERSEN: After things were pretty much wrapped up there in Dallas, I had somebody stay there to just finish cleaning up some loose ends, and then I went 00:08:00back to my normal job here in Fort Collins in the Division of Vector-Borne Diseases. But shortly thereafter, I got another call saying, hey, do you want to go to the White House to work with Ron [Ronald A.] Klain, who was the Ebola czar? I think I was appointed to do that, number one, because I had experience with Ebola, but also I had previously worked at the White House at the National Security Council there in the H1N1 flu [influenza] epidemic several years prior. So I did have knowledge of how the White House worked. So I got another plane and went off to the White House and spent another three months there.

Q: What were the White House's concerns at this point, and how did those mesh with CDC's priorities?

PETERSEN: The White House was trying to deal with a number of agencies who were 00:09:00all involved in the Ebola response. CDC was certainly a major player in this, but there was also the Department of Defense, who was helping us set up Ebola treatment units in West Africa. There was also USAID [United States Agency for International Development], who was also involved. [The US Department of Homeland Security] was involved, too, because of the monitoring of people coming into the country from West Africa and making sure they didn't have Ebola, because there was quite a concern about that. There were a number of federal agencies--the State Department was involved because they have people stationed overseas. There were a number of federal agencies that were all involved where there was really a need for higher level coordination, and that coordination was 00:10:00provided by the National Security Council at the White House.

Q: How did you feel that your previous experience working with them came into play for the Ebola response?

PETERSEN: I think one of the major factors was I knew what they needed, and I knew what my role potentially could be. One thing is that the White House operates on a very, very short timeline. They're operating basically on a news cycle. They have to react very quickly to unfolding events, whereas CDC tends to take a little bit more time, think about what's going on, analyze the situation and then make a response. There was the White House minute-by-minute timeline, as well as the CDC day-by-day timeline and decision-making, and those two didn't 00:11:00always mesh. [laughter] I was aware of that from my previous experience. One of my big jobs was to try and make sure that the information flow to the White House was there, and that the White House knew what was going on. If the White House doesn't know what's going on, there's always some suspicion about what's going on, and potentially, bad decisions could be made based on lack of information. I tried to meld the two, tried to get CDC to provide answers a little bit faster than they maybe felt comfortable with, but also to transmit information to the White House about what was actually going on and the thought processes going on at CDC.

Q: Can you tell me a little more about that info [information] that the White House wants to hear, what kinds of questions they're asking and where you're 00:12:00going to get answers to that?

PETERSEN: I think one of the big issues that was an ongoing issue was the status of people coming into the country from West Africa who were being monitored with fever. A number of people of course coming from West Africa may have malaria or any other illness that could cause fever, and they would be picked up and sent to a hospital for evaluation. [The concern about Ebola patients being brought into the United States accelerated, of course, after the nurses in Texas became infected]. There was very careful monitoring, and the White House wanted to know almost minute-by-minute the status of any patient that went into a hospital for evaluation. Whether the chance of Ebola was high or more remote, they wanted to 00:13:00know minute-by-minute what was going on. This obviously was a big burden for CDC in Atlanta, who was trying to track all of these patients.

Q: I assume we're talking about a lot of people here, right?

PETERSEN: Yeah. I can't remember the exact number, but there were hundreds and hundreds if not more than a thousand. I can't remember the number, but it was a large number of people that were being monitored.

Q: Was part of the job expectation management then for people at the White House?

PETERSEN: Well, there was expectation management, but also because of my clinical experience and experience with Ebola, because I am a medical doctor, I could translate medical information to the staff at the White House, giving them 00:14:00an appropriate level of concern. I could tell from the clinical history what the likelihood of the patient having Ebola or not was, and so that I think was very helpful to the staff at the White House.

Q: Again, I know it's been a long time, but do you remember any particular patients they were concerned about and how you were able to allay their concerns?

PETERSEN: I remember there was one particular kind of amusing or interesting event that happened. There was a patient that came in, was hospitalized in Minnesota, who had come from West Africa. The initial evaluation of the patient raised a pretty reasonable likelihood that the patient could potentially have 00:15:00Ebola. This was a patient that we had a little bit more concern about based on the initial information. This information came in late in the afternoon, of course as always, and then events were unfolding into the evening, and so we were quite concerned about this patient. Because of that, Ron Klain, the Ebola czar, went and informed the [US] President. I knew that because I was sitting there with Ron Klain in the White House. Ron Klain went to go inform the president that there was this potential patient. At the same time, the additional information that CDC was getting lowered the possibility that the patient might have Ebola, but there was still that possibility. Then the 00:16:00question rose, should somebody from Atlanta fly out to Minnesota to evaluate the situation? Unfortunately, it was late enough in the evening there was only one flight left, and it was supposed to leave in like forty-five minutes. There was this [telephone debate going on whether we send somebody to Minnesota on this last plane and rush them to the airport even though the possibility was lower that the patient had] Ebola. This debate was going on, and finally I said, "Hey look, if there's even a ten percent chance that this patient has Ebola, somebody needs to be on this plane and they need to get on it right now." I think at that point, CDC woke up to the reality of the situation, and then all of a sudden the 00:17:00train was leaving and we were going to send somebody to Minnesota. But the problem was at that point, somebody had to get to the airport in record time. Well, the White House at that point, since the former director of [the Department of] Homeland Security was there with me at the White House, he just made a few phone calls, held the plane until the person from CDC arrived, and they went off to Minnesota. That was somewhat of a tense situation, but that kind of--that is an example of how the needs of the White House and the needs of CDC were slightly on a different plane, but it all worked out in the end.

Q: Is one of the things that CDC is thinking at this point that we could send somebody out, but we are an advisory agency, and that technically the people on the ground should be able to take care of this?

PETERSEN: That was part of it, but not--the issue really was the information was 00:18:00coming in that made the patient less likely to have Ebola, based on further clinical evaluation. There was still the possibility, but the possibility was a lot lower than originally thought. However, there was still that possibility, and what was going through my head was the optics of not sending somebody to Minnesota if the patient turned out to have Ebola would be really, really bad. Based on that, my political sense of being around the White House was send somebody. The cost of a plane ticket [and the trouble were] worth it, just in case this patient by some far chance had Ebola. Because if there was a 00:19:00possibility of somebody sending somebody there to help the health department, and the patient turned out to have Ebola but we didn't do it, the optics would've been very, very bad.

[break]

Q: Can you tell me a little bit about--I think you mentioned offhand after we stopped recording in our first conversation something you referred to as "white papers" of people under investigation. Are these exactly the people you're talking about who would be coming over and be tracked for potentially developing Ebola?

PETERSEN: I'm not sure about white papers, but what happened was because of this concern about people coming into the country who may have been exposed to Ebola or had Ebola, that they be monitored. Because one of the issues of the White 00:20:00House was that they really didn't want to stop people from West Africa coming to the US in general. There was some thought by some people in Congress and elsewhere that we should just ban anybody from West Africa coming to the United States. The White House made the decision that we should continue travel between West Africa and the US. The feeling was that West Africa had enough problems, and adding more economic misery to that was not a good idea, and more stigma to West Africa was not a good idea. The decision was made to have people come in to the US from West Africa as they normally would do, but to monitor them. The way 00:21:00this was done, which actually turned out to be incredibly efficient, was they gave everybody coming in a cell phone that they could call and also a kit which contained a thermometer so people could monitor their own temperature and then call in twice a day with their temperature reading. That way you could monitor people all over the US--the state health departments could monitor anybody coming in to their state through the system, and it worked incredibly well. The compliance was ninety-nine percent. That worked out, and I think that system preserved the free flow of people coming from West Africa to the US.

Q: On another track, what was it like working with Ron Klain?

PETERSEN: I really enjoyed working with Ron Klain. He was one of the smartest people I ever met, and he really had a lot of experience working in the White House, so he knew how things ran, knew how to pull the right levers. Working with him was fascinating to see how he could actually work among all these different agencies and get people together and made decisions.

Q: Do you remember one thing in particular that he did that was remarkable to you?

PETERSEN: I think in general, what was impressive to me was his ability to grasp large amounts of information from a lot of different sources and synthesize it. He's a lawyer by training, so obviously didn't know much medicine like me, a 00:23:00medical doctor, but he could rapidly pick up the concepts and go with them and then formulate a policy. It wasn't just one particular thing, it was a whole series of events where we'd have meetings with the different agencies, and he would get all the facts together, formulate a decision memo in record time, and it was very, very well thought out. Very impressive individual.

Q: I know, as I mentioned earlier, that you go on to incident manage the Zika response here at CDC from Atlanta's headquarters, and you had previously led the H1N1 response. Is there any way that in broad strokes, you could characterize how this response work was different for you across these three particular responses?

PETERSEN: Well, first, I didn't lead the H1N1 response. I was a deputy of that, Steve [Stephen C.] Redd led the response. But I still had a leadership position in that response. I think each was slightly different. H1N1 was really an issue of trying to get vaccine produced and out there, so it was largely out to the communities in a very, very short period of time. That whole process was really a major center point of that response. It was much of a logistical issue around one thing, that was getting vaccine out there, but also informing the public, 00:25:00making decisions about school closures and that sort of thing. That was that investigation. The Ebola one was, I think, far different in that just the fear of Ebola raised the interest and fear of the public to even a much greater degree. Ebola involved a lot of informing the public about what was going on and allaying fears, but also with Ebola was the fact that it was an international incident to a much greater degree than H1N1, and so there were a lot of different players involved such as the State Department, the military, USAID and others involved in the Ebola response. It was a much more difficult situation in 00:26:00terms of dealing with a number of disparate federal agencies but also international partners as well and foreign governments. That's what made Ebola quite different. Then with Zika, Zika was a completely different issue in that we knew very little about Zika when the outbreak started. The whole world literature was like fifty or seventy-five scientific manuscripts over a fifty-year period. Certainly, there were a lot of scientific questions that needed to be discovered, such as, does Zika virus cause birth defects, or the whole issue of sexual transmission of Zika virus was unknown. We knew how Ebola 00:27:00was spread, we knew how flu was spread, but we didn't know fully how Zika virus was spread other than mosquitoes. The scientific parts of the Zika response were fairly unique because there was so much to be learned as we were trying to make policy and dealing with all the public health issues around Zika. It was learning while doing, practically, with Zika. The other thing with Zika was that it involved so many more people around CDC and that almost every center at CDC was somehow involved in the Zika response on a public health and scientific level. For example, the birth defects brought in obviously the National Center on Birth Defects and Developmental Disabilities, the sexual transmission brought in the sexually transmitted diseases people, the blood transfusion parts of this 00:28:00brought in another group of people, and the international part brought in the Center for Global Health. In the end, practically every single--in fact, probably every single center at CDC was involved, and that was the big difference there.

Q: To sum up, when you look back on Ebola, are there any general reflections you might like to give that we can put in our historical record at CDC Museum? Or any memories you have that really stand out that you'd like to describe?

PETERSEN: Let me think about this for a second. I think the thing that strikes 00:29:00me, and looking at--I've had experience in recent years with three major public health responses: H1N1, Ebola, and then Zika, and previously had experience a number of years back working very much with the anthrax attack after 9/11 [September 11th, 2001]. I think the one thing that strikes me is that the system that is set up with the Emergency Operations Center at CDC and the diverse set of skills around CDC make CDC very uniquely capable of handling major public health events that are strikingly different. There's a formula there that we've figured out, and we have the expertise here to provide support and staffing in a 00:30:00whole lot of different areas, and I think that we can almost handle these very disparate kinds of responses very effectively. I've been at CDC now thirty years, and over these thirty years I've seen our resilience to deal with these kinds of outbreaks really improve. I think we're a pretty well-oiled machine at this point.

Q: How much of that would you attribute to the staff in the Division of Emergency Operations, for example?

PETERSEN: I think they play a very big part in this. When we dealt with anthrax, we really didn't have that kind of expertise and people that were really dedicated to dealing with the logistics of emergency response. I think things 00:31:00fell through the cracks during that response. For example, I think our communication with state health departments and other partners really needed improvement. Just having the Emergency Operations Center with dedicated people who know how to deal with the logistics of an emergency response really has helped. They know how to travel lots of people, they know how to get people from here to there, they know how to set up the meetings that are necessary, they know how to deal with our partners and all the communications issues. I think that whole set-up really has improved our resilience.

Q: Are there any drawbacks to having CDC a little more focused on response 00:32:00activities rather than just having the technical expertise?

PETERSEN: Well, having the Emergency Operations Center provides the locus of activity for these emergency responses, but it doesn't provide the technical expertise. It's really that combination of having very strong technical expertise and a wide breadth of experience around CDC and the various centers working with that infrastructure that's developed at the EOC that makes this really work.

Q: I want to thank you so much, Dr. Petersen, for talking with me again after all this time. I really appreciate you joining me for this and I'll get you a 00:33:00transcript as soon as I can.

PETERSEN: Thanks, it's been a pleasure.

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