Dr. Martin Cetron

Dr. Martin S. Cetron

Q: This is Sam Robson here with Dr. Marty Cetron. Today's date is April 30th, 2018, and we're back in the audio recording studio at CDC's [United States Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. This is my second interview with Dr. Cetron as part of our CDC Ebola Response Oral History Project for our David J. Sencer [CDC] Museum. In our first interview, we talked about Dr. Cetron's life and career leading up to the 2013 to '16 Ebola epidemic in West Africa, and now we get to dive right into his experiences with the epidemic. If we could just start at--where would you say your initial involvement was in the response?

CETRON: My initial touchpoint, because our division is part of the National Center for Emerging, Zoonotic, and Infectious Diseases, and one of the other divisions in our center, the [Division of] High Consequence Pathogens and 00:01:00Pathology that Inger [K.] Damon leads, is in our center; we started hearing about Ebola in West Africa, I would say March of 2014, I believe. It was fairly early. At that point, it was thought to be a geographically circumscribed outbreak of Ebola in the Gueckedou region right at the intersection of Guinea, Sierra Leone, and Liberia in the Mano River area. It was a remote, forested area. I remember at our center updates when we would all get together to discuss the issues, Inger talking about the first cases, how the epidemic was shaping up, the deployment of the CDC team. At that point, all of us were totally unaware of what would transpire over the following year and a half after that. 00:02:00But for its unique location in West Africa, it was another Ebola epidemic that CDC would deploy in with assistance from others and from around the agency in trying to put out this epidemic before it got too big.

Q: At that point, you are the director of the Division of Global Migration and Quarantine, right?

CETRON: Yes. We're hearing about this and a lot of things. We maintain a daily situation awareness report, we're following global epidemics on a regular basis for their implications, how they're growing, whether there's the capacity for it to grow beyond its current confines, whether we're going to be called to step up to provide assistance as needed from the lead division, which was Inger's division, and in what way we would help, what types of advice we might be 00:03:00offering up for people who would be traveling in to respond to the outbreak, or people who happened to be going to the area. Those are all sorts of the things that we're keeping an eye on. Is there a risk for it to spread beyond the current confines? What's the connectivity to the United States and to other countries in terms of global pattern, global distributions? What kind of protective measures would we be recommending people take as they fight the epidemic?

Q: Was it taking much of your time back then?

CETRON: We would meet regularly. Our division wasn't front and center. It was by no means the front line of the response, but we were keenly interested in hearing how things unfolded, as we are with almost any one of the serious, high-consequence pathogens that break out and create outbreaks. As you are well aware, this was by no means the first Ebola epidemic that CDC was involved in, but there were some unique features. One of them was the region of the world. It 00:04:00had not been reported certainly with any regularity of having Ebola in West Africa before. That was unique. Other aspects of it appeared like they would be similar to other Ebola epidemics past, and with international assistance, the hope was over a period of four to twelve weeks, the whole thing could be brought under control, minimizing the size of the epidemic, bringing education and information around and trying to get it under control and snuff it out.

Q: When does your part in the response start to accelerate?

CETRON: As we moved beyond spring, I think there was a time where there was a sense that the local epidemic was under control and the CDC team was preparing to depart and there was just--I'm trying to remember a ways back, but a couple of oddities about whether this was really the whole picture. I think there were 00:05:00sporadic cases, or reports of suspect cases, popping up on the periphery, or beyond the original affected area, and as we moved from spring into early summer, it seemed to be more and more concerning that the geo-scope of the epidemic was no longer contained to a single village and that there was connectivity beyond that. The popping up cases across the tri-country area and around these borders started to really raise our level of concern. A multifocal Ebola outbreak in West Africa, in a new region of the world, seemed to be just unusual enough to get our concern. As we got further into May and June when cases were persisting, and certainly by early June, there were discussions underway at CDC and beyond that we needed to really ramp up the level of 00:06:00awareness, alerts, and concerns in all sorts of different directions. I believe it was around that time--I have been, for a number of years, part of a roster of experts that consults and supports the World Health Organization on the International Health Regulations, and the International Health Regulations provide for something called an Emergency Committee. An Emergency Committee could be convened by the Director-General of WHO, of global experts around pathogens to assess their impact and whether they represent what's called a Public Health Emergency of International Concern, or a PHEIC. There were some concerns, and I was sending some messages to colleagues at WHO about, were we going to have an emergency committee on the Ebola situation in West Africa? I think we really needed one. The pattern of cases popping up in disparate 00:07:00geographic locations was pretty concerning. That was really ramping up both my individual personal involvement as a consultant on the Emergency Committee and expert on the Emergency Committee, as well as our division's involvement and thinking about international containment.

Q: What kinds of things were you hearing back when you were having these conversations with people at WHO?

CETRON: I think that there were shared levels of concern all around, but it was unclear as to exactly what the path forward, from WHO's perspective, would be at the time. I know that there were a lot of plans that DG [Director-General] [Margaret] Chan [Fung Fu-chun] and her team were having about engaging in the region, getting the countries in the region to request international assistance, looking at the exact scope of the problem, as well as the magnitude of the problem, coordinating in three countries. I think there was a lot going on with 00:08:00WHO and regionally, and I'm not sure that they were necessarily prepared to open this up to a global international response until they had a better sense of what was going on in the region. There was a lot of shuttle global health diplomacy, I would call it, that was going on back and forth that I recall. But the issue was heating up and getting hotter and hotter and there was a lot of pushing to really move to some of these next steps about declaring a Public Health Emergency of International Concern, mobilizing international assistance, getting larger numbers of teams involved, and this was happening beginning in May and June, I think.

Q: I'm trying to remember when it was that Medecins Sans Frontieres, MSF, declared that there needed to be a massive input of resources.

CETRON: Yes, it was around the same time. Many different groups were sounding 00:09:00the alarm actually before the WHO official declaration of a public health emergency of international concern, that comes from--the DG convenes this Emergency Committee of which I was part. They deliberate. We make recommendations, and then the DG makes a decision. Ultimately, I'm trying to remember. I think it was much later. It wasn't June. I believe it might have been closer to August.

Q: I think so.

CETRON: We can look that up to be sure. Something tells me August 8th is the timeframe. It took a while, but alarms were being sounded. MSF, CDC, other people in the region. It was clear that this was not a typical Ebola outbreak that was going to snuffed out in a period of twelve weeks.

Q: I know that you're aware of some of the criticism that has come at WHO about why wasn't this PHEIC declared earlier. What's your perspective on that?

CETRON: It's a lot easier to make sense of the world in the rearview mirror, in hindsight, and so I would say yeah, there were all these red flags, which when you look in the rearview mirror, you've got the benefit of knowing what happened and filtering out all the noise and all the wishful thinking. The truth is, we make sense of the world in the rearview mirror, but we experience and live the world looking through the windshield, as it is. I think there's plenty of criticism for lots of groups to go around about reacting sooner. Sometimes that's easier to say in retrospect that in real time, and I know the people--my colleagues and friends at WHO that were heavily engaged. They were no less concerned than anyone else. I think truly, it was unclear what the best paths forward were, and in hindsight, it was a slow response, no doubt. Whether that could have easily been seen looking forward or not, or what the reasons for 00:11:00that--hard to say. I'm not one who's necessarily overly critical, other than the fact that reflecting on what could be done better always helps us improve going forward and there are many lessons that we all learned from this outbreak after months and years, in fact, of engaging with it--many things that none of us anticipated transpired during Ebola in 2014 and 2015. But yeah, the response was probably slower than it should have been and maybe that would have made a big difference. We certainly would do things differently going forward.

Q: Do you remember many conversations about the effect of a potential declaration on the economies in the region and--

CETRON: Sure. There are all sorts of conversations that happened. You're balancing the need to sound the alarm and mobilize resources against maybe overreacting to something that's containable with less effort, to doing 00:12:00something that would bring on undue, unwelcome, negative attention, stigma, fear. It's a very, very delicate balancing act. Epidemics like this of disease--I might have mentioned this to you in our earlier conversation--are often conflated and confounded by epidemics of fear and stigma, and they all go hand-in-hand. If you think about the International Health Regulations, even the way they're worded, it's to contain the threat while minimizing interference with international travel and trade. You're always looking for a sweet spot. All those conversations--and I've been on emergency committees in WHO for Ebola, for pandemic influenza, SARS [severe acute respiratory syndrome]--many, many situations like this, and we always have those kinds of debates in the committees. When's the right time? How much is needed? Is the geo-scope large? Is the threat significant? How far will it spread? What are the potential 00:13:00benefits and detriments of sounding those kinds of alarms?

Q: Right. I'm sorry, I'm going to be asking you to repeat information here, I apologize. As the division DGMQ [Division of Global Migration and Quarantine] got more and more involved, what kinds of activities are--

CETRON: Some of the first things that we got involved with, and this was quite early, I think early in the summer, even before the WHO declared the public health emergency, it was clear to us that one of the things that needed to be done is to figure out a strategy for containing further international spread. We saw the Liberian American diplomat who flew out of Liberia after attending a funeral of his sister, I believe it was, into Lagos, Nigeria, and collapsed on the tarmac and set off--one individual with Ebola set off ten to twelve weeks of 00:14:00Ebola cases in Nigeria that took an army of people to squash out. Into Lagos, Nigeria, one of the most populated countries on the continent, with huge amounts of connectivity to the rest of the world. It was very clear that there are many stages of fighting an epidemic that are a lot like fighting a fire. You fight it at its source. You set up a series of peripheries of fire blocks and buffers, and in Ebola, it's the same way. You want to fight it at the source as strongly as possible, but you also need to be able to contain it and create buffers of containment. That first buffer of containment at the international border level involved making sure that no more cases of active Ebola would be able to fly out of one of the international airports to other countries. So we deployed a large team from our division into Liberia, Sierra Leone, and Guinea, particularly at 00:15:00the international airports, but also at some of the seaports as well, and we worked with and trained these countries in how to set up a linkage between the public health community and the transportation and infrastructure community. This is something that we've prepared and planned for domestic strategies for decades, going back to early pandemic preparedness and in SARS. We basically took the strategies that we had. In this case, it was exit screening, and for other nearby countries, it was entry screening. These countries wanted a border management structure to be sure that active cases of Ebola wouldn't be flying out of those countries, exposing people on planes and in landing and creating the situation that we saw in Lagos. But also setting up, helping countries in 00:16:00the nearby area that had shared land borders and high crossing points set up entry screening programs. These involved lots of kinds of things--the case list and the contact list of cases who needed to be isolated and treated, and contacts of those cases who were under observation, contact tracing quarantine, if you will; that those people who were being followed by public health, that that information was also being shared with the transportation industry infrastructure so they wouldn't be given airline tickets and so on. That linkage, recognizing that this was a whole-of-society kind of approach to this type of global containment effort. Those linkages aren't necessarily built perfectly in high-resource countries, but certainly in places like Guinea, Sierra Leone, and Liberia, building that connectivity and that infrastructure is 00:17:00important. Usually, you're working from scratch. That was our first big engagement.

We were also developing analytic structures to look at the transportation in and out of these countries. Who is going. How they're going. How often they're going. Whether we would issue various degrees of elevation of travel advisories. We have three stages of travel advisories in increasing severity. One is heads up, there's an outbreak. It may be that this is the kind of outbreak this country will have all the time, but this is really worth paying attention to. It's out of the ordinary. Level two would be you know what, this is bigger than any routine outbreak and there are special precautions beyond the normal precautions that people need to take. In some cases, it would be certain populations for whom the risk is too high to go, or special types of 00:18:00interventions that would be needed or sub-locations within the country that really should be considered off-limits. Level three is our highest level of alert, and in this case, what we're saying is the risk of discretionary or elective travel to the region far exceeds the benefits and people just shouldn't go. We have a whole set of criteria for each of these levels for both raising them and lowering them. But it's a graded scale. We're in full gear in developing these type of international recommendations, which is often mimicked by countries around the world and frequently in parallel with what WHO's global recommendations would be regarding travel and trade.

Q: Do you remember when your level went--the moments when you decided to increase--did it increase up to three?

CETRON: Oh yeah, and stayed at three for a very long time, and there were a lot of criteria to get there. Including if the epidemic is so large that there's a 00:19:00collapse of the healthcare infrastructure, that anyone with any health condition couldn't safely get care, or that the outbreak is so unpredictable in some regards, or the transmission is so intense, that you simply couldn't discriminate where or when you were likely to be exposed and get sick. That was the case very quickly in the West Africa outbreak, both in terms of the geo-scope, the magnitude, and what we would call the unlinked cases where cases would pop up, and absent the really detailed investigation, you couldn't recreate the chain of transmission. That actually tells you that an epidemic is moving very fast, in an unpredictable way. That you can't keep up with where the next cases are. That they're not just occurring among people who are known contacts from a single case, but all of a sudden, this person over here and this one there in three new villages. Those are usually the kinds of things--unlinked chains of transmission, out of control, very lethal disease that if you get it, 00:20:00you have a high probability of dying, or diseases for which there are very few countermeasures for protection. Those would be the criteria that put us into that level. I can't remember the exact date, but we were there in the summer. We were there long before the August 8th declaration. We had said that all travel to those three countries should be postponed, absent people who were there from a humanitarian perspective of responding to fight the outbreak. For those populations, we gave special precautionary advice on how to stay safe while you were there fighting the epidemic.

Q: Is there some amount of diplomacy that you have to do when you make those travel advisories with those countries?

CETRON: Yes. I would say it's not a negotiation, but it is a fair warning. One of the principle responsibilities that we have is to try to be apolitical in that sense, and that is once we meet our criteria, that threshold applies no 00:21:00matter what country you are, whether you are a friend of the United States or not. Those factors don't come into the consideration. It is really based on pretty firm public health criteria. But recognizing that it has cascading impact, we provide advanced notice. We do communications, firstly cleared within CDC and HHS [United States Department of Health and Human Services], but we also provide advanced notification to embassies and to the ministries in those countries, and we give advanced warning before we actually take those steps so that they are prepared and they understand the rationale and the criteria, both for coming on and for coming off of that list and how that process works. Again, not a negotiation, but we do try to provide a minimum of twenty-four hours' advanced notice to doing those things.

Q: And you were able to meet the twenty-four hours with all three countries?

CETRON: Yes, by more than twenty-four hours. We saw things coming, we knew this was going to be necessary, and we provided those heads ups and people that have 00:22:00equities in that decision, are impacted by that decision, were all given plenty of notice, including notifying WHO. And because I sit on the Emergency Committee for WHO, there's a conduit for providing that information. The Emergency Committee at WHO also deliberates at an international level about those same types of recommendations. On the one hand, we're sharing our criteria, we're sharing our modeling results, our perspective on it, and the other thing that happens in an Emergency Committee is the affected countries are also invited to talk about what's actually going on with the epidemic. What are they doing to combat it? What types of control measures are they putting into place? Do they have exit screening at the airports and so on, and what types of assistance do they need? This is an international conversation all with a common goal of mitigating the risk and the threat. There aren't really surprises in terms of 00:23:00this is coming. This is something that's discussed in great detail with the people that are affected as well as the people that have equities in it.

Q: Right. What kinds of things are you hearing back from the governments in the region or other people who had a stake?

CETRON: Everybody has a stake. My experience is that sometimes, early on, an affected country gets representation in this discussion and then they aren't part of the deliberation. It's a two-part format. The affected countries have times to present and answer questions from the Emergency Committee, then they disconnect, and then there's a discussion among the experts on the committee about the way forward. It's not unusual, and in fact, most often is the case that there is full consensus in the Emergency Committee around the direction and recommendations that are offered to the Director-General. I think it's also the 00:24:00case that most times the Director-General heeds the advice of the Emergency Committee. It's her decision or his decision, but it's commonly so well-discussed and thought out with clear evidence being brought on all sides that there's usually a pretty firm consensus around that.

Q: I'd like to know a little more--sorry to switch gears a little bit. You were talking about sending the teams from DGMQ into the countries to try and align the public health infrastructure or knowledge with the people in transportation and get that more hand-in-hand--get some information sharing going on.

CETRON: And setting up programs for exit screening. This often is a multistep process of risk assessment and then risk management or risk mitigation. A risk assessment may be you are talking to somebody about their potential exposures. You're checking whether they're on a list of being a case or being a contact of 00:25:00a case. You're getting a lot of detailed historical information. You may be doing a quick physical assessment--may be doing a temperature check with the handheld remote thermometer, and those are a series of steps that any one of those--if any information is found as you move through those steps, then the person is set aside and undergoes a more detailed evaluation and health assessment. The whole goal, in addition to continuing things and not allowing for additional spread, is also to get somebody rapidly, appropriately diagnosed, cared for, and treated in the safest setting, as well. The purpose of this is both for the benefit of the individual being identified and tested and evaluated, as it is in the benefit of the receiving community.

Q: Did you find that there were differences in what your teams were able to work 00:26:00out across the region?

CETRON: Uniformly, the capacity to do this and the experience of the airport workers and the transportation sector and their whole linkage with the public health sector. Did that capacity exist? They hadn't trained, prepared, exercised for an event like that. The other thing one has to be cognizant of is that if you're the Ministry of Health [and Social Welfare] in Liberia and you've got this raging epidemic or fire in your back yard, your first priority is not to worry about exporting disease. Not that that's not on your mind, but that's not what your first priority is. Really, when you think of the beneficiary of that type of exit screening strategy, the beneficiary is for the international community. My opinion, and I think shared by many, is that the international community has a responsibility to provide this global assistance where the capacity exists. We have been building that capacity in the twenty-plus years 00:27:00that I've been in the division in terms of preparing for these kinds of things, so we were more than happy to try to share the instruments, questionnaires, tools, noncontact thermometers, staging grounds, the proper PPE [personal protective equipment] that the workers needed to have, how to have a clinic nearby, what you do when somebody has a fever, that's appropriate, not always assuming every fever is necessarily going to be an Ebola case--all of those things. That's what we brought to the area, initially prioritizing the international airports. Then we moved to seaports in some of the areas where there was a lot of commerce, and in addition to land border crossings.

Q: Would it have been then around August when these teams were going out or earlier?

CETRON: Earlier, but certainly they were all in place before the declaration in August. I'm thinking I'm remembering in either June or July we first started doing this. And of course, the request for our assistance kept growing. As the 00:28:00epidemic grew across the three countries, certainly when it got involved in capital cities, which is where international airports are, and then the exportation to Nigeria, and then land border spillovers into Senegal and a couple of other areas. The affected countries needed that assistance for exit screening. The surrounding countries with high connectivity needed that assistance for entry screening, and we were doing analytics of trying to classify tiers of countries at risk to prioritize where the engagement would be. It got to the point where the effort in international containment from that prospective--the border containment strategy--got large enough that we were actually bringing in people from all over the agency and training them in what we did to sort of leverage and train the trainer on that--the demands and the requests were exceedingly high.

Q: How did that go? I mean, who were you bringing in to help?

CETRON: As you probably know from the project, a lot of CDC--thousands of CDCers were involved in the Ebola epidemic.

Q: I think it's at four thousand or something like that.

CETRON: Yeah. We were a core team in the response to the global strategy for community mitigation and border health and control, and we assessed what our needs and resources were, and within the emergency response structure in the EOC [Emergency Operations Center], we solicited all sorts of different capabilities. When people volunteered and joined our team, we just trained them and put them to work wherever they were needed. A similar thing happened when we finally got the clear direction after the introduction in the fall of the Dallas case that we were going to expand to yet another layer. The layers had been, fight the epidemic at the core, and you probably heard a lot about that from Jordan [W. Tappero]. Fight the epidemic at the borders and make sure it didn't spread. And 00:30:00then, as each country took various types of protective posturing and eventually the outer layer was protecting against entry, then the most significant next-step layer was every hospital in the United States needs to be prepared in the inadvertent situation of receiving an Ebola case, of how to make sure that that was an N of 1. That's how this type of concentric circle approach to a global epidemic plays out.

Q: Did that mean that you were doing some work with, for instance, the Medical Care Task Force that was in the EOC?

CETRON: Yes. We were the Global Migration Task Force. There was the Medical Care Task Force. There was the Infection Control Task Force. There was Surveillance and Epi [Epidemiology], and all of these get integrated about where cases are and cases that get found and you have to retrace all their travel history. The Ebola case in Dallas exposed some nurses. One of them was traveling to Chicago. 00:31:00I can't remember exactly--

Q: I think it was Ohio.

CETRON: Ohio, yes, for wedding dress shopping, right? She was determined--they had some symptoms on that flight, and then we were responsible for finding every single person on that plane and monitoring, tracking them down and all those and so on and so on. It can be quite a tedious and exhaustive effort, but it has to be done because these fires leave embers, and any one ember is capable of starting another fire, as the Nigeria experience indicated. There's really very little tolerance for missing a case.

Q: Were you having regular meetings then with the people who were in charge of preparing hospitals here in the United States?

CETRON: The information around how hospitals would be prepared and setting all of that up, I'm not sure if you've been interviewing those folks, as well.

Q: I've talked with John [T.] Brooks and Abbigail [J.] Tumpey, as well.

CETRON: Yeah, they were on that, and we would basically say, what's CDC's best 00:32:00advice around personal protective equipment and donning and doffing PPE? All those kinds of things. Well, the people that we're putting in harm's way at the border posts want to know what that is, too. What degree of PPE do they need for an encounter? Although the risk of a border encounter with an Ebola patient--the probability of that is much smaller than the probability of encountering it in an Ebola treatment unit, you still need to decide based on the risk, what level of precaution are we going to take in these different settings? And what are the principles behind that? That's how it all gets woven together inside an emergency operations center structure. But every group--a new report of a suspect case somewhere means you're going to go run that case down and, if there's any travel exposures, you're going to reach out to that, so there's a huge amount of intersection with all of our groups and trying to stay coordinated, which is why the meetings go on constantly, almost 24/7 00:33:00[twenty-four hours a day, seven days a week] at the height of these things.

Q: Let's talk about your day-to-day at this point.

CETRON: The day-to-day is now shot, and we're fully moved into--by certainly in the summer, and I can't remember specifically, but we were part of when the EOC was originally stood up to deal with this response, our task force was in there from the beginning, and we maintained a task force eighteen to twenty-four months that went nonstop. During the heat of it, that 2014 year, we were staffing it all the time and it was pretty much all hands on deck. We had the skeleton staff back in the division running what we called continuity of operations for core mission stuff, but this was clearly the big--the Super Bowl of [epidemics, or "SuperBola."]

Q: Yeah. This is a little bit of a tangent, but what kinds of things do you need to have continuing--what are the core things that you have to say okay, despite 00:34:00Ebola, we need to keep this going?

CETRON: Well, we run all the immigration health screening for the United States.

Q: Okay, well, there's that. [laughs]

CETRON: We have to continue--we have seven hundred panel physicians around the world executing our mission of immigration health screening for TB [tuberculosis] and everything else. We have three thousand civil surgeons in the United States doing immigration screening for people who adjust their visa status from temporary, student, or worker, to a green card holder. That needs to go on. We have other threats that we're monitoring on a daily basis. We have a major responsibility in global TB control with regard to how it touches the US. That goes on. We've built laboratory capacities. We do refugee resettlement activities. All of these things are influenced by and shaped by the threat picture in the globe, but Mother Nature's pathogens don't stop just because of Ebola and sometimes they're exacerbated by it. If healthcare infrastructure is 00:35:00collapsing, then you're going to have more vaccine-preventable diseases and all these other things. If there's a lot of fear, you're going to have more emergency migrations. Sometimes that means larger refugee populations or wars that are going on intersect with this. We have this core amount of regular day-to-day work--situational awareness, threat assessment, threat mitigation, communication, standard responses with embassies and everybody else, and then you have the emergency on top of that and how that's shaping all of it. What happens when there's a suspect Ebola case in a refugee camp in a population that you're actively involved in moving? How are you going to evaluate and get a sense of that--close down the movement until things are safe and so on? So there's plenty to do. Fortunately, during crises like that, we also have emergency resources that we draw on and we surge up. I think something like a 00:36:00twenty-five percent increase in staff during the year of Ebola.

Q: Where did those staff come from?

CETRON: All over. Sometimes we were recruiting them out of the clinical community, students, annuity hires, so we bring people back from retirement and resurrect them for the fight and get them back in the game. They're all over the place, and then the amount of volunteerism around big events like this is impressive. But yes, we're looking for specific skill sets, and we're surging up, and we're bringing back retirees, engaging in enrolling students from schools around the country, medical students, other workers from other parts of the agency. Everybody is in a fight like that. It's a big one.

Q: One of the things that I've heard a lot about is the burden that's put on 00:37:00people who work in a given division when others in the division go to deploy out to West Africa.

CETRON: Yeah, it's hard.

Q: How did you see that in DGMQ?

CETRON: I could tell you how I see it in retrospect. When you're in the middle of the fog of war, you know what your mission is and you know how important the priority is and you're going to move whatever resources are needed to get that under control. We also have and have had for a long time a strategic plan with a continuity of operations. We knew what stuff we had to be able to deal with. I would say what I learned in retrospect that I did not appreciate at the time is that we used to just swing, right? The epidemics--SARS, I think the intensity of SARS was about a three-month thing. We would swing everybody over and get that under control and then would swing back to operations. What we have had recently--I would say in the last decade, but certainly the last five years or 00:38:00more--is a series of these events, one after another. Where there's Ebola and then there's MERS [Middle East respiratory syndrome] and there's Zika and prior to that, it was pandemic influenza and then unaccompanied children at the border. We were responding constantly, and there was no surge swing. Everybody runs a sprint, and then you rest them out, and then they go back and they're fully charged to do something after a week's break. We're now in these intense, multi-battlefield marathons. We needed to essentially create a double workforce. We had to have a core group of people, one, that like and respond to the intensity of emergencies and do well and thrive in that environment. There are people who do and there are people who don't. Then, to basically have a set of people who can always mind the core operations, that don't get pulled into response, while people who love being in response do that. And redundancy in 00:39:00staffing. When you're running a response that's 24/7, that's three people for every one job description because you've got three eight-hour days that you're trying to deal with, and so accurately assessing the resource needs, not to burn people out, not to break them, and to be able to continue operations. It's almost like you need four-fold staffing. You need three times your normal staff to be in the emergency response if you're going 24/7. That can drop when you scale back. And then you need the regular, eight-hour staff shift of people that are just doing what you always did. As the director and the manager together with my principal management official, [J.] Todd Mercer, we have realized that we need a fighting team and a peacetime team. We need a wartime team and a peacetime team all the time in order to go on with what's happening in the last five years. Mother Nature is constantly throwing the curveball at us. If we're 00:40:00lucky enough to be in a respite, great. People have earned and deserve it and they catch up on sleep and visit family and all those things. But we can't afford to try to burn people out constantly. Because if they're not taking care of themselves, they're not going to be able to respond and do well in the emergency.

Q: Did you see some of that?

CETRON: Absolutely. There's the emotional trauma. There's the physical--the time demands of the trauma. There's the persistency of it. I mean, the Ebola response went on for close to two years.

Q: I guess I should have asked--did you experience some of that? I know the answer to that is yes.

CETRON: Yeah, definitely. The other thing is those of us that do this for a living for a long time have, I think, sometimes this false notion of our own invincibility. Somehow you think, if I'm doing God's work, I'm not going to get 00:41:00sick and tired and burnt out and all those things. But the truth is, that's fanciful and that's just about denial. The reality is creating a buddy system where you have other people tap out and say it's time to go home, you need a break, you're here too much. Or, as a leader of the division, for me to set a schedule that does not allow me or anyone to take advantage of the enthusiasm that CDC people have for responding to these kind of crises. We can be our own worst enemies in that setting if we're not really careful about how to train and balance for a marathon. Examples that the leaders set make a huge difference in what people feel is the permission they have to take a day off and rest up and so on. It's odd that you think you have to say that, but when you're geared up for the big one like that, you do have to remind people that you can't be good in the fight if you're not rested and good to yourself. That's a big part of it.

Q: Is that something that you've been able to try and institute, some of those reforms after the Ebola response?

CETRON: Yeah, even in the middle of it, we're always reflecting. In the middle of it, we changed shift schedules. We shortened shift times. We didn't allow people to work these twelve-hour days. We set rotations up. We insisted that everyone have a minimum of a day off every seven and two days off after--some persistent amount of recovery time. We had these buddy systems where people recognized when somebody else really needed it, even if they wouldn't say so. Inside the response there were teams that were set up just to focus on the resiliency of the responders. Those were really important lessons. We did a lot even along the way. But what I realized is that I had been underestimating the overall staffing needs of my team to be able to do continuity of operations and 00:43:00emergency response, and so we've restructured it and we've restructured our position descriptions in the division so people who are suited and want to be involved in the response work, it's written into their description. People who clearly don't like it or can't respond in that way, but make huge contributions otherwise, that's sort of carved out, as well. Single moms, of which we have many. They don't want to feel guilty or bad for not participating, but they are participating when they're doing all the other stuff that still needs to get done. There is a certain amount of that kind of awareness, and it's one of those things that it would be nice to teach it in a book, but it doesn't get learned that way. It gets learned through experience, basically.

Q: When you were sending people out to West Africa and the three most affected 00:44:00countries, the ones surrounding them, making sure that you're setting up entry screening for those, as well, how did you choose who went out?

CETRON: There was an abundance of volunteers, so it wasn't a matter of having to--nobody was forced to go that didn't want to go. There were more people that wanted to go than were needed. We set up rotations. We balanced what skills they had--that only they had that were or were not needed here--whether there was a dopplegänger that could fill in the role that they had back--there was no shortage of people who wanted to be in. It's like, people train their whole careers at CDC for something like this, and not that anyone wishes it on--but that's why we do--people would say that phrase, "Super Bowl." This is the big event, and you have a skill that's needed, and there's this huge amount of adrenaline about being able to do something and make a contribution and a 00:45:00calling. There was no shortage of volunteers in my shop.

Q: Are there some calls with people overseas that really stand out to you when you look back?

CETRON: Oh, there's too many to even think about. There's so many phone calls of all sorts of natures. Whether they're with embassies or with posts or incidents or potential exposures or safely evacuating healthcare workers. We were deeply involved in all the return of Ebola-affected healthcare workers to the US facilities, accidents that happened in the field where a healthcare worker went down and several colleagues were assisting in resuscitation, and a lot of people had high-risk "wet" exposures that needed to be returned and monitored in the shadow of a US Ebola treatment unit, but really couldn't fully come back to interacting in their community. All sorts of ethical questions around quarantine 00:46:00and where and how many and how and what would the restrictions look like. Early on, we had to set up the movement and monitoring guidance document that took weeks to actually really navigate through, and across all of the parts of the US government. Who was going to be allowed to travel? Who needed to be isolated, who needed to have restricted movement, and then what degree of restrictions are appropriate, based on the exposures? We had these four or five categories of exposure types and would recommend different intensities of restrictions. Right down to people wanting the specifics. Can I go to the grocery store? I'm asymptomatic, but I had a high-risk exposure. Can I go to the grocery store? Can I walk on the street? Can I run in my neighborhood or not? All of those types of questions and conversations.

Q: So at the macro and the micro level, it sounds like.

CETRON: Exactly. Because it matters. These are the things that matter to every individual. They also matter as national policy and global policy, as a matter of fact. The Emergency Committee sometimes would ask what different countries are doing with regard to quarantine policy around movement. And movement restrictions or who they're letting into the country and all those kinds of things.

Q: When did your work on the movement and monitoring guidance really pick up?

CETRON: Pretty early on. That's a question that comes up right in the very beginning. I would say we were engaging in that certainly in the early part of the summer.

Q: Okay, so before Thomas [E.] Duncan.

CETRON: Oh, yeah, yeah. This went back to right when the outbreak was even happening. You've got to make those decisions as you go to the field, and what makes sense in the local setting, and recognizing very quickly that much of the Ebola spread was happening through movement and migration and unrecognized 00:48:00movement of people who were exposed. The truth of the matter is that there's much more international mobility and local mobility than anyone ever imagined. That if you flew over the area two decades ago or three decades ago, and now in the Mano River three-country area, you can see the road network of connectivity that [expanded]. That this has always been a complex region in which the political boundaries are more arbitrarily defined than the kinship or linguistic boundaries, and when people have an existential threat and they get sick and are dying, they are going home, either to die or hopefully recover amidst loved ones. That's what people do when they're threatened in that kind of a [way]. They're moving and they're going to cross land borders and sea borders and air borders. They're going to get to where they feel the safest place for them to 00:49:00get support for this existential threat.

What hasn't been appreciated, and much of the work that we've done in the time since Ebola is actually mapping out those networks. We've been drawing both the physical maps of connectivity, but also the cultural maps, the linguistic maps, the healthcare clinic network maps, the systems, and these have really panned out in a very important way when we think about smaller outbreaks. Like Lassa fever right now in Nigeria, which has spread into Benin and Togo. Working with those countries to define the migration streams. Nigeria imports a lot of migrant workers from Benin, and there's a Lassa fever outbreak. The network in which those migration patterns come from are dictated by a skill set, a language skill, a cultural connection--all those kinds of things. You can map them, and 00:50:00you can anticipate what the trajectory, the international trajectory of an epidemic is going to look like by knowing them. Then, sick people who are on the move have healthcare needs along the way until they get back. If you overlay that map with health posts, you know where those people are likely to be seen. Those are health posts that you can prepare in advance for when the febrile person comes in, take the right steps to presume it's Lassa or Ebola or something else, and contain it at that setting. Even if you're not able to keep them from moving, you know where they're likely to be going on this route by looking at these types of overlays of culture and movement maps. We're doing a lot of work like that across the African continent right now at the requests of these governments.

For example, I'll just tell you one story with regard to Lassa. There is a need for migrant workers who have a certain ability to till the soil type in Nigeria, 00:51:00where that experience--that's in the southern portion of Nigeria. But in the northwestern portion of Benin, there were farmers or mine workers who had those skills. So there was this path down there. And there was a woman who, as a migrant worker, was exposed to Lassa on the southeastern border of Benin, but in Nigeria. She got sick. She was pregnant. As people, as I said, will do, she decided to go back home. Along her journey up until she got to the northwest corner, she delivered her baby by emergency C-section [cesarean section]. It was a bloody delivery. She had already had Lassa, and nobody knew. The husband, who was originally from Togo, came and took the baby. The mother died in childbirth before it was diagnosed as Lassa, and so now the husband from Togo has the baby with Lassa infection after a maternal death in a migrant worker who came from 00:52:00the outbreak area. By being able to trace that sort of sociocultural aspect of things, you can then better prepare this route. It may be waterways that cross borders. It may be land bridges. It may be marketplaces where people stop and gather. It may be clinical facilities--all these places can be enhanced with surveillance or education or detection or a variety of tools.

That was all something we learned, the importance of these conduits. This cultural migration. The UN [United Nations] defines an international migrant as someone who lives outside their country of birth for more than twelve months. That's the official definition. There are between two hundred fifty and three hundred million people on the planet right now that fit that definition of an 00:53:00international migrant. They are both north-south, east-west, rich-to-poor, poor-to-rich--they go in every amalgam. There is regional migration. There is global migration. But there's a lot of it, and some of it is economic and some of it is forced displacement, but all of it is people on the move and all of it actually posed this--they are part of this circulatory system of the planet. Understanding that network is actually critical to understanding how to combat global emerging infectious diseases. Because some people in different countries are more connected by that circulatory system then they would be by proximity.

Q: What was the state of that work at the beginning of Ebola for the three most affected countries, though?

CETRON: It was pretty primitive. It had to be defined, and I think that locally, 00:54:00people understand that a little bit, but there's a lot of local hesitancy to share that information. If people think that you're going to use it to prevent them from getting to a family or prevent them from going home for a funeral, then you've got a little bit of a tension to deal with. I've said for a long time in my last two decades of experience at CDC, if there's one skill set that I think we could hire more of and we're certainly deficient in, that's medical and cultural anthropologists. We could really use people who understand those types of aspects of the network. We've got a lot of people who understand the bug, and we have people who even understand host susceptibility and risk factors. How HIV [human immunodeficiency virus] impacts the host or malnutrition and all of that. We understand about host vulnerability. We understand more and more about virulence of pathogens--not that we've mastered them by any means, 00:55:00but the area that we're weakest in is the third pillar and holy trinity of infectious disease, and that's the milieu, the context in which things are occurring. I think if there's one area where we completely missed the boat early on in Ebola is we missed the boat on the milieu, the cultural context. If we had known what we know now about that network, the cultural network, the movement, the risks, the behavior patterns, the percent of cross-clan marriages, the traditions around burial, the traditions around when someone's sick or has a loss in the family, where does the surviving person go back to be supported, and those things. If we understood that better, we might have been able to get ahead of the curve. We were mostly chasing Ebola from the rearview mirror. We were behind it constantly.

Q: I have imagined the Duncan case in the United States in October as a moment 00:56:00of shift--a turning point.

CETRON: It was the catalyst.

Q: The catalyst. Did you experience it that way?

CETRON: No doubt. In fact, I was on the way over and I remember the call very distinctly. We had been discussing entry screening as that next layer in the United States in the US government for many months, and my feeling was that it was going to require a lot of resources, and we had a way where you put that. Should we scale up more of the work we were doing closer to the epidemic, or did we really need to have a control layer here? We had protocols for dealing with a sick person en route. We had exit screening and a lot of stuff. We knew we were taking temperatures of everyone who's getting on a plane to come here. The thing about the Duncan incident is while I didn't think the milieu was right for a 00:57:00widespread, massive Ebola epidemic in the United States, I think there was some overconfidence about the ability of any hospital or any clinic or any community to manage a case. That management assumes you know what the patient has. The biggest other surprise about this is that the intensity of denial--that healthy, normal, human-nature-based denial. That when you have a fever, your head does not let you go right to Ebola any more than your first blood in urine or in a bowel movement takes your head right to cancer. Basically, there are a million reasons, and fevers are common, so you'll blame malaria. You'll blame the flu. You'll blame a respiratory infection, a diarrheal illness, a bad meal, long before you're going to assume that. Because that's the healthy denial, or maybe not so healthy, but that's the denial that we use to survive on. That's why people present late. Well, that denial is not only paramount at the individual 00:58:00level, but also in an institution. I've heard a number of healthcare workers where one comes down with it and they want to go in. They talk to their supervisor and say they shouldn't be operating anymore. I've had a fever. It could be this. Take me off the roster. The people above will say no, Dr. Jones [note: hypothetical name], you can't have Ebola. It's just not possible. You're over-worried. We need you. And so that stuff goes on. It's the same reason people come to the office sick when they have influenza. I'm not contagious. It's just allergies, right? That level of denial, first of all, is human nature, and secondly, you need a system that overcomes that temptation.

What we saw in the Duncan scenario was first of all, he didn't know he was exposed. He was doing a good deed. Some kid in the apartment, a mother had a kid who got a fever. She came and said, "Can you help get him to the hospital?" A 00:59:00kid with a fever. All that common. He did a good deed. Took him in the car, dropped the kid. Never was there long enough. Secondly, incubation period can be long. Right up to twenty-one days in that setting, and so he was fine. Thirdly, he had planned a trip to leave. He had no known contacts or exposure to his knowledge. He passed all the screening tests. We went back and checked. He also never even had a fever when he left West Africa. He was totally--he gave honest answers and he had no indications.

Q: You actually had records of that?

CETRON: Yeah, because we were part of the screening program and everyone that was leaving--so as soon as he came in, we could retrace his entire route. The flight, the time, the person, the time of his encounter. We had all the records. This thing that surfaced that he knew he had Ebola and he came here to get different treatment was completely made up. That was stigmatizing fiction. That wasn't truth. He was unassumed. And only when he got here did he have some of 01:00:00these early symptoms. He had a fever. He had some stuff. He didn't allow himself to think that that was a possibility because he didn't think he had an exposure. His family didn't encourage him otherwise. Then when he finally went to a clinic--I think he went to two clinics and was dismissed with the diagnosis of a cold or sinusitis or something and given antibiotics, so that denial is profound and pervasive. That permeates the system. Part of that transformative aspect was one, there's much more denial than we think, and even if you're not contagious until you're actually sick, the fact is that people don't go from being well to unwell in an instant where a light bulb goes off and it says Ebola, Ebola, Ebola. You need a system that is not dependent on that to occur, which does not happen in human nature, in order for you to be safe. That's why we have quarantine. It's not because everyone in quarantine is contagious when they're 01:01:00asymptomatic. It's because you don't know where you're going to be when you get sick. You need to have this buffer of planning for that tomorrow. He has his own denial. He has his family's denial. He has the clinics' denial, and then he's in a hospital in an emergency room and he's now quite sick and contagious, and our assumptions about how prepared our hospitals were, were wrong. We were overconfident in so many ways. These types of things--the levels of overconfidence, the not appreciating the amount of denial, building a public health response system that accounts for what human nature really looks like. People who are sick move, and they go home to family and relatives to get care and die. That's what they do. People who get sick initially are usually in denial. Other people that are taking care of them don't want to be thinking about that. We needed systems that were much more robust to the normal frailty 01:02:00of human nature in this aspect. That was the wakeup call about the Thomas Duncan thing. Even though I would maintain that as a country we weren't as vulnerable to the same size of an Ebola outbreak as we were witnessing in West Africa, the risk tolerance for a single case in that level of uncertainty and the fear that's generated around that and the stigma that comes with that, are consequences that need to be managed. Our entry screening program, which on the books that we prepared for was supposed to take six weeks to create, build, and turn key, and I was told six days. Figure it out--get it going--we need a protective--so we mapped all the traffic. Every port that had flights, direct or indirect. Staffing needs. We decided we would do five ports so we get ninety-five-percent-plus of all the traffic, everyone else would be forced to go 01:03:00in that way. Built the entire program in a week.

Q: In the week following Mr. Duncan--

CETRON: Yeah, pretty much. The thing got turned on, and of course you remember it was midterm elections and there was a lot of politics in that issue. We had a zero risk tolerance setting with a highly fatal pathogen, a lot of fear, a lot of stigma, a lot of calls for overreacting. There was a time in that October when eighty percent of the public and eighty percent of the Congress was calling for a complete shutdown of all connectivity. I don't know if I shared this with you in the earlier conversation, but the problem with these kneejerk overreactions is they actually increase your risk. What happens is they play into that denial. The response to denial is that we have a superpower and we'll build something--a fortress so strong that it'll be impenetrable. And that's 01:04:00fool's gold. That just doesn't happen. People migrate when they're in existential threats. Just look at people at risk all around the globe, what they're willing to do in dinghies to cross the Mediterranean and the Atlantic to escape war. They do. If you don't set up systems where you account for human migration, but you deny it and you pretend you can battle against it, what you really do is you drive it all underground. People go into hiding. They find routes to travel that they won't be discovered. If you acknowledge that the safest way to manage inevitable migration is actually to build yourself a risk assessment and risk mitigation strategy, then actually you're keeping your eyes on the problem.

What we did with entry screening is, first of all, with exit screening--when we started that, three hundred fifty thousand people safely left the international 01:05:00airports during the period of the Ebola epidemic without additional air-based spread. On entry screening, thirty-five thousand people came into the United States from those three affected countries through our five ports, also without additional spread. But what people don't know is ten percent of those thirty-five thousand, about three thousand five hundred, actually had an early symptom that was compatible that could have been Ebola. A fever, a bleeding episode, anything that would have been the earliest indicator. Every single one of those people--ninety-nine percent of those people were identified as soon as that onset of that problem, and they were managed safely as an individual without putting their family or the other healthcare workers or other hospital systems at risk. Because we had a program that wasn't so much about finding you a new Ebola case on arrival. We had enough built up to sort of prevent that. What we realized with the Thomas Duncan case is that someone easily, unknowingly 01:06:00could have been incubating and could get Ebola in the next twenty-one days. So what are we going to do about that? The whole strategy was the same kind of tiered risk assessment. It was called the CARE Program. Check And Report Ebola. And CARE Plus, when we added the cell phones. What we built is a reason for the individual to overcome their own denial. We said, you've got to check your temperature every day for twenty-one days. If you have a fever or anything, any sign of illness, on this card is the first number you call to get good advice, to get an early diagnosis, and to get the best available treatment. Whether it's Ebola or malaria or foodborne illness or a diarrheal disease, we can guarantee that if you're aware and you check in, we're going to get you an answer and we're going to get you treatment. You're not going to be at risk to yourself, you're not going to expose your family, and you won't become a pariah in the community.

We had a creative program. The CARE program was all about winning the hearts and 01:07:00minds and recognizing that there is actually no control without care. If you don't build a care-based incentive for people to be cooperative, there is no control and containment. Because control and containment without care is a very selfish concept and it doesn't give you any alignment of incentives for people to cooperate. This was about reaching not only their head, but also their hand and heart. Give them something to do. Give them information for their head. Give them a message that reaches their heart that says why you should do this. And thirty-five thousand people for twenty-one days, every day, were managed safely with the Ebola entry program that was set up. Certainly in my twenty-plus years at CDC, I've not seen a public health cooperation at the federal, state, local, transportation, community level that was that effective in that regard. People 01:08:00asked me, how much did it cost? We've got papers coming out on the total cost of the program. I say what it cost, which is a few million, in comparison to what the cost would be of not having it, which were astronomical. Shutting down the infrastructure of the transportation sector to the globe could have risked not containing the epidemic in the first place. When you think about the confidence that was built. Congressmen came and visited me at all these ports, and when they saw the program, including the one who originally proposed the shutdowns, said, you know what? You got this. We think that this is the way to go. When I told them what the consequences of not having eyes and ears on the problem would be and driving all this movement underground and how much the risk and threat would increase by not knowing who's coming and going from where, they were all in complete agreement. That's the kind of thing where your first instinct may be 01:09:00wrong. The fortress approach, that I'm invincible if I build a big enough wall, versus, where are the alignments of incentives? How do you align care and containment? Basically, what I wrote about there is it's all about building trust. The whole thing is about the ability--in an epidemic, you can have technical expertise around the pathogen, you can have a brilliant understanding of risk factors for who is going to get sick and who is not, but if you don't understand the milieu and you don't build trust with the victims and if you only see victims as vectors, you will never succeed. That was a sobering and humbling lesson.

The other one is not only should we not be overconfident about getting past the 01:10:00human instincts of denial, but in reality--maybe I've said this to you before. I can't remember. Stephen Hawking, who recently passed away, had a great quote. "The enemy of knowledge is not ignorance, it's the illusion of knowledge." There is a huge amount of illusory knowledge that we hold around things when we think we understand something and we take it for granted, and in Ebola, also in Zika and so many other things, we just need a lot more humility about what we think we know and what we actually know. Can Ebola be spread other than through the wet secretions, i.e., can it be sexually transmitted in semen? How long does it last? There was a lot of illusory knowledge based on the Ebola that we experienced before that just didn't translate, and maintaining humility and an 01:11:00open perspective and building yourself a system that is robust enough to handle the normal inadequacies and frailties of human nature and recognizing that technical expertise is necessary but insufficient if you're facing a bankruptcy of trust. Those are some of the really core lessons.

Q: I want to talk about you visiting the ports of entry. But could you use a break for a second?

CETRON: No, I'm good.

Q: Cool, well let's get into it. What led to you--let's see, were you at all five airports?

CETRON: At some point, and initially, we had the first start of this at New York at JFK [John F. Kennedy International Airport]. It was JFK, Atlanta, Chicago, Newark, and DC at Dulles [International Airport]. Those were the five ports, and 01:12:00the reason to be there is, although we had talked about in theory a structure, we had developed concepts of operation for what we called "risk-based border screening" for more than a decade, back into the early--post-SARS. We'd really talked about what that would look like with different pathogens, and how we would structure and stage, and what we would do, and how we would manage people that hit the triggers and interfacing. We'd never really executed a full-on implementation of this concept. This is just like anything else. There's nothing like being on the ground, and if you go to any port, you've just seen one port. The physical structures, the flow, the people, the engagement. Not only had we not done this, and we were the tip of the spear from public health in 01:13:00implementing and instituting--we had critical partners across the government and outside of the government at the community level. Emergency responders, hospitals, ambulance drivers. This was a really intricate, big network that needed to function seamlessly, and nobody had ever done this in this way before. Part of this was not only figuring out what the physical landmark would be in every different location, but also we had CBP [US Customs and Border Protection] officers that were way outside their comfort zone. They were in law enforcement, and they were involved in the primary assessment and screening. We had datasets that were being captured. We had contracted people from the Coast Guard to do the initial temperature checks. We had lots of people that were in a lane that was untraditional and unfamiliar, and there was a huge amount of fear. Some of those people were listening to the global rhetoric about, why are we letting 01:14:00anybody in in the first place? Isn't it safer just to stop all this? Being there, it was really important to actually try to address this epidemic of fear and risk of stigma. But a lot of fear. That often meant daily "musters" of these just-in-time educational messages, where before a shift started, I would--in the middle of a room full of CBP officers, I would just start, "How many of you are afraid to execute this mission?" Once the first few hands went up, everybody's hands were up. "What are you afraid of? What worries you? What's most on your mind?" Just bring that out to a conversation. Not expecting people to do something because they were told to, but to actually get them to understand it. Most of the time, the fears were in excess of the reality of the risk. What they mostly needed to hear was no, we weren't expecting a massive inflow of 01:15:00Ebola-infected people at the port. This is what was already going on before anyone would ever see them. This is what they could do in terms of, they were wondering about wearing all sorts of protective equipment. I said, "You're not in an Ebola treatment unit. You don't need to be dressed up to that degree. The likelihood of you having an active case sitting in front of you is really, really, exceedingly small. This is mostly about doing the risk assessment so that people in the future can do risk management once someone's sick. The sickest people are never being allowed on the plane in the first place." They didn't know we had this infrastructure upstream, or what was going on. Then every time a shift turned over and the new people were coming in, it was doing that all over again.

Q: Do you remember any individuals in particular who were freaked out about their role?

CETRON: There were several, and not in any way judgmental, I've worked with law 01:16:00enforcement before. I've been in other situations where there was a security threat and we were in caravans going in and out of refugee camps and we were under armed guard and so on, and I felt very afraid because I didn't understand that risk. I'm not sure how much that risk was actually mitigated by me wearing a flak jacket or being in a caravan. But I couldn't grapple with my understanding of the threat or the measures that were done and how safe I was. So, I'd seen people in law enforcement training who will go into a room with active shooting scenarios and know exactly how to address that threat. An unseen pathogen that can liquefy you scares the hell out of most people. You may be a very brave soldier with a gun or CBP law enforcement officer, but Ebola is not a threat that you have a handle on. I think a lot of it is just allowing people to 01:17:00express their concerns, to go through the protocols and procedures, to say what's in place that's protecting them and their family, and why we wouldn't put them at excessive risk in this setting. Again, that kind of activity is a big deposit into a trust account. If you're willing to be there and spend the time and explain this, or meet all the people that are in the line without any protection, then they know that you wouldn't be doing that--exposing yourself unnecessarily, and it can't be that unsafe for them.

This scene was repeated over and over again at every port. The problem with a lot of international flights is they come in all day and all night. It's always on, and there was a lot to learn, and the flows were large. I found myself with 01:18:00very few hours of sleep over the course of setting these programs up. Mostly, we have an isolation room. It's really an examining room. It's like an examining table with stirrups and stuff, and I was basically sleeping on the exam table in the isolation room for a few hours between events for weeks on end until this was set up.

But I do think it was a very necessary and a very successful program. I didn't think that back in June when we set up exit screening, and I wouldn't have done that in lieu of doing exit screening, which had a higher yield. But I do understand why it was a necessary step, and there aren't a lot of situations in which I think that's an appropriate strategy of control, but there are some. I would also argue that when you battle an epidemic of disease and also are 01:19:00realistic about the epidemic of fear and stigma and you take all three of them into account, you're probably in a better place than if you try to get by on these narrow, scientific definitions of "I'm only going to worry about the epidemic of disease and not deal with the epidemic of fear." I think fear actually increases the risks of exposure and transmission in ways that people don't appreciate, as does denial. So I think it's necessary to have strategies that embrace all of that. The vaccine for both ignorance and illusion is basically education. That's what we have, and a lot of that standing up of programs like that, once they're strategically designed, they basically rely on a heavy component of education and communication and confidence-building and 01:20:00trust-building in order to be able to execute.

Q: Now, this would have been October-November?

CETRON: October-November timeframe, yeah. That's when it started, but we did it almost for a full year.

Q: Really?

CETRON: Yeah, twelve months. We had these criteria for when the threat was decreasing enough, and we left exit screening in place a lot longer than we had entry screening in place, as I think is appropriate. But we also showed that you can start something and end something. After SARS, a lot of Southeast Asian countries never stopped their entry screening strategies. They just maintained a permanent stance on that. If it wasn't SARS, it was going to be MERS or it was going to be pandemic or something else, and I don't think that you necessarily have to have that in place at all times. It is resource-intensive, and these things should be selectively used. You've got to hit the sweet spot to get this 01:21:00right, and there are many things that we're balancing in this regard.

There's a lot of questions you ask in this setting as a policymaker when you think about the strategy. The two that always get asked are, may I, is there authority? And can I, is there a capacity? The question that often does not get asked is the should I. Even though we have this authority to do that, we may--and we've now proven that there's a capacity to do it, albeit with a lift and a surge--but is it appropriate? The "should" part is important, and it's not always the right thing to do. Knowing when it is or isn't and how to listen broadly about whether it is or isn't the right time and what should be done, and is it the right balance, is this the most impactful way with the least restricted means that's necessary. It's not too hard to overshoot, but usually 01:22:00it will backfire. You're usually taking a big withdrawal on the bank account of trust when you overshoot beyond what's needed, and if you are really attempting to be thoughtful about the strategy and you start it when it's needed and give a good rationale, and you end it when it's not and you give a good rationale, you're probably more likely to be trusted when the situation comes around the next time.

Q: I think that was one of my big takeaways from our previous interview, was that need to ask "should I" when all the focus is on "can I." There was a New York Times op-ed at some point that I read that I didn't completely understand. It was basically arguing that in the wake of Ebola, we need to make sure that quarantine authority remains with the states.

CETRON: Oh, yeah, that op-ed written by several people I know. I was cautious 01:23:00not to respond. It was right when our new rules were going up, our new quarantine regulations, which I had been working on since 1996, when I got in. The stars never aligned until very recently about why we needed to revise hundred-year-old quarantine regulations, which clearly were outdated both in terms of the threat picture, but also in terms of the milieu of global transportation and travel, Mother Nature's threats--all these things were wildly different from when those regs [regulations] were first introduced. But the regs came out, and there was a notice of proposed rule-making the fall before public comment, and then the rule, and then the rule was passed on January 19th, before the new administration. Then it was on hold until it was reviewed by the new administration, which not only did the past administration fully support it, but the new administration also fully supported it and it went through. But people 01:24:00misinterpret a lot of things in there. They actually read things in there that weren't the case. That there was language in there that gave the feds [federal authorities] power for mandatory, invasive medical procedures or forced vaccination. All that is not in there. There were comments that what was in there was--you know, the federal quarantine authority is actually quite limited. I might have said this before. International arrivals; interstate spread; federal properties within a state like Native American lands or congressional buildings; requests from a state for assistance when they don't have their own capacity; and the fifth and the sort of least-often used is failure of local control. There were some discussions around Dallas of whether there was failure of local control and the feds should have taken over that situation. Ultimately, the feds didn't. There's a lot of collaboration and cooperation and support. But it's fairly limited.

Some people were misreading in that New York Times article, written by a lot of folks who really were not as well-informed as they should have been--misinterpreted one of the provisions in there which said the responsibility for a captain to report illnesses in the old regs would go to whatever the local jurisdictional authority would be. Well, the truth is that state and local authorities don't stay up day and night waiting for illness reports from the captain that wants to land a plane. What this rule said is that--and the pilots won't do it, they refuse to do it. They don't even know who the local health official is at this place, and if they did, they might never be able to reach them in time to make that decision. This rule consolidated it, and it said all reporting by any captain of any conveyance about a suspect illness that meets our criteria goes to one hotline number in the EOC at CDC. I have a 24/7 response capability for that, and as soon as we know, we have the call-down 01:26:00list of every single local public health person, and we know who to alert, and we alert them immediately. But the likelihood of getting that call is infinitely greater because they've got one place to call. We put it on a ring card that they wear around their badge. Somebody from an Ebola area is throwing up blood on the plane. Bing goes the CDC EOC. Next call, I'm getting it. My team is responding. The local quarantine officer has a jurisdiction across each of their jurisdictions in every port and knows every public health official that needs to be brought into the loop and all that happens. So they misread this thing that the feds were trying to consolidate power. It just wasn't the case. But there's a lot of commentary from ivory towers of people who don't work doing it every day, and it's okay. I appreciate the input and the thought. But I think they 01:27:00were misguided.

Q: Does CDC have--I know that the DGMQ is--CDC is not a regulatory agency, but the DGMQ is closer.

CETRON: We [DGMQ] are a regulatory agency [note: program]. We're the largest component of--not agency--we're a regulatory unit. We're the largest regulatory component at the agency, [CDC]. Yes, FDA [US Food and Drug Administration] is a bigger regulatory agency than CDC overall as an agency. But DGMQ was its own entity for a couple hundred years before there was a CDC, and it had all this regulatory authority, both in immigration and in quarantine and isolation. It was the federal regulatory agency around the spread of communicable disease, and the Foreign Quarantine Service is what it was, an independent entity in the department. It was absorbed and came to CDC in 1967--we're celebrating the 01:28:00fiftieth anniversary this past year--and it brought all of its regularity framework with it. It's true that as CDC was originally conceived during CDC's founding, it wasn't about being a regulatory agency, but it absorbed a regulatory agency in that regard and so we have that. There are other parts of CDC that have regulations--the group that deals with monitoring movement of pathogens, shipping of pathogens around the globe and so on. There are other places, but we're probably the largest one with the biggest amount of regulation. It's a privilege. In a lot of other countries, particularly the five I countries, the immigration health sits in their immigration departments, not in their public health departments. We're lucky that we were set up with this [responsibility inside CDC]. The division has a dual mission of preventing 01:29:00importation and spread as a regulatory responsibility, but also a public health responsibility of reducing health disparities and all of those things. I think if you are charged with executing that, it's good balance, it's a real advantage to have both the regulatory leverage and the public health perspective in one place. That way, it gives me the opportunity or the privilege to see regulation as just another prevention tool, not an end in and of itself. Enforcing regulation is not the end. The regulation is there to achieve a particular public health purpose. It is one of many tools in a public health toolkit, but not the only one. Whereas when you sit as a part of a regulatory agency, your focus is all about, what am I permitted to do? What do I have the capacity to do? And I'm just going to enforce it. There's not a lot of discretion to ask the "should" question in that space. And we have that privilege.

Q: I want to go back to something that you said in the first interview. You 01:30:00mentioned that there were a lot of emotionally laden memories during your response work for Ebola. Are you alright with sharing one or two of those moments?

CETRON: Sure, there are several. They relate to suspected exposures of colleagues; moving people back and forth; the [toll of the human] tragedy as it unfolded. You've read some of my reflections on some of those experiences. Just being engaged for so long--six months before we really saw a bend in the epidemic curve--was chilling. The extent of devastation and human suffering was 01:31:00just unbelievable. Also, I thought that at times these tough decisions about where to find that right spot. The balance between restricting civil liberties and the balance I guess of care and containment. Understanding that there's no control without care, and there's really no care without control. You've got to have these together, and there are not a lot of times where you're asked to put that in place. Everywhere from the local level to a sick and dying child to an orphaned family member to a just national policy. But having to adjust your microscope lens and find the right balance in all of that, from the individual level to the community level to the state and national level, to an overall 01:32:00policy that is both fair and appropriate. Those are tough things. It's difficult. Because you're working largely in uncharted territory.

I don't know if I've mentioned this difference. I think about a complicated problem and a complex problem. A complicated problem is like when my daughter comes to me with her math homework and there's a ton of variables and she just is overwhelmed. She says, "This is really hard." I say, "It's complicated, but you have a set of rules which you know to be true and you apply them and you'll reduce the complexity in this equation until eventually you're going to get an answer." And it's going to be a knowable, right or wrong answer in that sphere of math. But you're basically applying a known set of truths, and you're just 01:33:00trying to disentangle the complication by the many unknowns. You're applying a set of rules. Fighting epidemics like Ebola and others like this, they're not the same because it's more than a complicated problem--it's a complex problem. There's much more unknown than is known, and there isn't any set of right answers and rules, and everything you do is going to have a collateral consequence or effect, intended and unintended. You really don't actually know. You can apply everything, you can gather data, you can create some information, you can even accumulate a body of knowledge about the epidemic or the experience. But the wisdom is something that is derived from experience, and experience teaches us that a lot of what we think we know is illusory. What's your system going to be to solve a complex problem with all these interacting? It's much harder, and so I think the humility is really important. Setting up 01:34:00independent observations and lenses into the window is important. Doing something that I heard fighter pilots do with these OODA loops--observe, orient, decide, act, part of a training that I went through in national leadership preparedness training. But being constantly present to the fact that you have to make some observations. You have to reorient to the problem as it currently is. You have to make a decision. You have to act, and then suddenly the whole dynamic is changed again, and you have to keep doing that. Complicated problems, you drill down and you solve by teasing them apart. Break them into simple components. Complex problems, from my experience, you actually have to go up as opposed to going down. You need to have a much bigger picture of the problem, and for me, a complex problem requires the thirty thousand and the fifty thousand foot level of observation where you see effects on the system and you 01:35:00set some goals. But then you have to go right down immediately at the local level, and you've got to get that feedback. Constantly moving from the very local, on-the-ground scenario. How did this play out? Did it play the way I thought it was, or what was the other side, collateral effects? And are they moving toward the goal?

Q: Was there a time during this epidemic that you really had to reorient--

CETRON: I think several times.

Q: --where you saw yourself going in one direction, but then the situation had changed?

CETRON: Yeah, you mentioned one of them. Just setting up entry screening. I'd been pretty much against that in the early part of the epidemic, thinking that it was more than was needed and that more of the resources needed to be concentrated locally. But I came to appreciate the perspectives that forced that, and once we committed to doing it, I was committed to trying to make lemonade out of lemons of that decision, which came certainly above my level in 01:36:00terms of "this will be done." But there were others. The balance of isolation and quarantine--quarantine is a spectrum, and it can be individual. It can be community. It can be geographic. It can be risk-based. There's a lot of ways to interpret that. And it can be completely misused. The power of quarantine to misuse is quite high, and history is replete with examples. The way it was applied in West Point in Liberia was problematic. Barbed wire and military force. That instinct to trap people in goes against everything that I believe about developing trust and care and containment and aligned incentive systems. What you saw is privileged people escaped under the wires. You saw the fear that 01:37:00turned into the mask of anger, and the anger and the fighting back and letting patients loose from clinics and all sorts of nightmares occurred as a result of the misapplication of that authority and power, and figuring out how to do that right was really hard. That played out even in the small number of cases we had in the US, whether it was Kaci Hickox or the New York City physician [Craig Spencer] or Thomas Duncan. This idea of how you adjust the balance of individual civil liberties and human rights on one side, but protecting public good on the other side and getting that right. It's hard.

Q: Do you remember a moment where you really had to take a stand one way or the other?

CETRON: Yeah, I think a lot of times around the development of movement and monitoring guidance. Policies on evacuation, creating--where we were going to 01:38:00establish to people who had high-risk exposures. I think there were a number of these areas where--

Q: I know it's been a long time ago.

CETRON: No, you know, there's a lot of internal debate about some of that stuff. Because somebody will come back and say, "I'm not contagious until I have my symptoms and I'm not symptomatic, so I should be free to move however I wish." My point is, that may be true on an individual basis. The truth is you don't know where you're going to be when you have your first symptom. And not everybody needs to be restricted, but if you were a healthcare worker in a situation with a high-risk wet exposure and no prophylaxis, it's not responsible of me to say you should be able to go to the grocery store and if you have a fever, you go home quickly. Because that's just not responsible. My responsibility is to have the whole in mind and not the individual, and to make 01:39:00sure you have a set of principles that guide that, that are bulletproof against the ways in which those powers and authorities have been misused by privilege or wealth or status or whatever it would be. Part of the thing that went so awry with the Liberian American diplomat was that he was a diplomat, and the way in which things were handled in that setting--the amount of privilege affected the outcome, and making sure that you can set a set of criteria that will really withstand some principles that rise higher than the inevitable scrutiny that will come from the individual, whether they're an NBC reporter or a physician, Dr. Spencer or whatever. Those are tough, but once you set a set of principles 01:40:00that you think are fair to live by and then everybody lives by them, including CDC employees and your colleagues and friends, you've got to hold the line.

Q: Were you involved in some conversations with people who had come back who had had--I know that nobody at CDC came down with Ebola, of course.

CETRON: Yeah, but people had exposures and people got fevers, right? And that's really what you're managing. You're not managing the rearview mirror of their diagnosis. You're managing looking forward, sometimes with and sometimes without the headlights. That's the kind of decisions you have to make, and you have to weigh all of that and say, these are the principles we're operating under, and ultimately that has to be front-and-center of how you--

Q: Did you find that people coming back who had had exposures that were CDCers by and large understood?

CETRON: Yes. That didn't reduce the amount of denial, and sometimes it didn't reduce the fear. Sometimes, as I said, and myself included, sometimes we're in situations where we think because we're on the side of justice that we're 01:41:00invincible to the consequences of our risks, and that's just foolish. Sometimes you have to protect people against themselves in some regards. But that's human nature. I don't fault anybody who had all those range of emotions. That's the way people behave. It's our job in creating policy and in executing things to accept that people don't execute life with perfection as if they had learned all their lessons in the rearview mirror. We don't drive looking in the rearview mirror. We drive in the fog of war and rain, with windshield wipers that don't always work, and sometimes there's a headlight out. That's the situation in which these kinds of things unfold, and sometimes it's really hard to distinguish signal and noise in that situation. You need a policy that's robust enough to actually deal with the way the world really works, not the way we wish 01:42:00it would be.

Q: For sure. I've kept you here for a long time. One thing I want to make sure I ask is, who were some of the people who you worked the most with? And if you can describe your work with them.

CETRON: I worked with a huge array of people, clearly my own team and the leaders of the different groups in our team, on a constant and daily basis. But also across the leadership of the agency, there were a lot of us that were engaged regularly. Communication folks, the CDC director, the incident manager, all the subgroup leaders in the EOC. People at WHO on the Emergency Committee, in the actual CDC part of the response. I spent a lot of time with media. I've 01:43:00never met a more dedicated group of people who I felt really wanted to get it right, including the time in September when we had a visit from the president and we briefed [Barack H.] Obama on each of our areas and so on. I was really proud of the way the responders took their mission and their task, and people were absolutely committed and brought their best selves to the engagement, and also they were human beings affected by it. It was a tough outbreak. Probably the toughest of any that I've been part of. But I didn't run into anybody who I felt was doing anything but their level best to pick up their role in this whole thing and realized how much we all needed each other's insights and wisdom, 01:44:00their collegiality, their teamsmanship, and I think some of the best things about working on big epidemics like this is that you build a deep set of abiding friendships from that bond--that shared experience. Like you hear people who go to war and face battlefield commitments and loyalties and experiences.

Q: Like brothers and sisters in arms?

CETRON: Yeah, that's exactly what it feels like. You get tremendous respect for humanity in that setting. I think the world of my colleagues here.

Q: We have talked about quite a bit. Is there anything that I should have asked that I didn't ask? Is there anything that you'd like to talk about or reflect on that you haven't?

CETRON: No. I think I did mention to you my thoughts about humility and trust 01:45:00and the role of culture and context, and I think probably this more than anything really hammered home the poignancy of that, and that's not something that in 1992 when I came as an EIS officer I would have thought would have been such a big component about getting this business right. But it's the Achilles heel, and I think it's the make-or-break of it all. The longer you stick around, the less you realize you know. [laughter]

Q: Great. Well I look forward to being completely ignorant when I get older. Thank you so much, Dr. Cetron, for coming here and dedicating your time. This has been fabulous.

CETRON: I appreciate your interest. Thanks a lot.

END