Dr. Martin Cetron

Dr. Martin S. Cetron

CETRON: There were a number of emotionally laden memories about the response. It was a long response, one of the longest. I've been doing these responses with CDC [United States Centers for Disease Control and Prevention] for twenty-six years and this one was the toughest in a lot of ways. There were some really hard ones, SARS [severe acute respiratory syndrome], [influenza] pandemic, monkeypox, and MERS [Middle East respiratory syndrome]. There's a lot of them that were [challenging], but this was uniquely different and difficult and it was a big chunk of your life. It wasn't a three-month SARS thing where you get in, you sprint, and get out. You go through a whole series of [emotions]--it's a bit of an emotional rollercoaster. There are various points along that way where things stand out.

One of them which was a consolidating, almost a processing cathartic experience. In September of '15, I think that's probably right, I was asked to give an 00:01:00hour-long--I'm Jewish, and that time of year is our New Year's celebration and Yom Kippur, kind of a holy day of the year. I was asked to try to explain and tell the Ebola story to a congregation, to a group of about one thousand non-technical people, as interpreted through certain kinds of teachings and Jewish text and make a linkage between the time of year. They call it a d'var. I had prepared for it for months and then given it in late September, early October of 2015. That was a pretty emotionally laden time.

There were many others. The various times of pleading with the WHO [World Health Organization] much earlier. I sit on the emergency committees of many big responses for WHO, and trying to argue the need for action sooner [in this outbreak] than they were ready and willing to act. Transporting the first people back here to Emory [University Hospital], to others, hearing about exposures of colleagues and safe extraction. I run a large program and have a set of responsibilities that is both international and domestic, and at the time during Ebola, our team size was four hundred-plus. We had one hundred people probably cumulatively working in the field. The October surprise and the October events 00:03:00happened, and the '14 pre-election, and Thomas Duncan and all of those things. I was called back to set up the domestic program at our airports and spent the next several weeks living in five quarantine stations trying to stand up a program that we had been designing for pandemics of influenza and had never really implemented, but had created a lot of exercises and plans and strategies around. We said once the decision was made to operate an entry evaluation program, we would need three weeks to stand up and get functional, and the White House said you've got six days. [laughter] You've got six days to create a USG [United States government]-wide, second-layer safety net, because most of our [border effort] was concentrated on containment at the source. Coming back to 00:04:00build a domestic firewall and trying to live in the old quarantine station at JFK [John F. Kennedy International Airport], sleeping in the exam [examination] rooms, finding all the old history. Some of those memories sunk in. Mostly the fear and stigma and the emotional heartache of wrenching with the situation where your instincts for self-protection are exactly the wrong thing. The violation that occurs between--the instincts you would normally use to cope to survive are the things that you have to completely let go of. To me, the biggest thing which I wrote this d'var about was that this epidemic showed what happens 00:05:00when there's a "bankruptcy of trust." Trust everywhere: personal, familial, institutional, governmental, societal, international relations. It just was a fundamental bankruptcy of trust and it didn't matter how technically good our agencies or our collective skillsets were. In the absence, in the bankruptcy of trust, which is very hard to reestablish in the middle of a crisis, that was the single most significant driving factor that was extending the epidemic. That and a certain lack of humility which is reflected by a favorite quote of mine from Stephen Hawking which is, "The enemy of knowledge is not ignorance, it's the illusion of knowledge." There were a lot of illusory beliefs that got in the way 00:06:00of the kind of open mindedness that's needed when you're facing a new emerging threat. You may think you're familiar with the pathogen, but it's not just about the pathogen, it's the pathogen, the person and the milieu as an intersection, and sometimes what you think you know just gets in the way of what you need to be open to, to find a better way out. If you had to boil down what I'll tell you in the next hour, it's bankruptcy of trust, humility, logistics.

I guess the other really key theme for me was the world was looking for control and the suffering victims of Ebola were looking for compassion. Control without compassion or care, however you want to look at that. It's not like people 00:07:00didn't care. But if the priority was protecting everybody else to control the epidemic from spreading, which was critically important--doing that in which you didn't establish a right to care, my job as the director of the quarantine program is to constantly balance the line between protecting the public's good and interest while respecting and understanding the needs of the individuals who were victims of disease. That's what I've been doing for twenty years, trying to walk the tightrope. I think there's a lot of false dichotomies out there about those being "either/or." In the easiest sense, you can say either we protect the public or we engage and provide care to the victim, but you can't do both. Well, I fundamentally disagree with that. I think these are false dichotomies. There are ways to do public protection and compassionate care [while protecting] 00:08:00individual rights. Treating people like victims and not vectors. But that's the tension: is it a victim or is it a vector, do we extend compassion or do we restrict and contain? And you can do both. It's an intensive process, and it may be in the front end more resource-intensive to find the least restrictive means and to thread that needle, but in the end the absence of doing that process creates an untenable seesaw between epidemic control and care, buy-in, and trust. You're building trust when you create the balance in that tension. I think those were the themes for me over two years. They were vividly illustrated, it was intense. I have never seen so many people committing so much of their time, energy and emotional blood, sweat, and tears to work on an 00:09:00epidemic and yet feeling so helpless about that ability to control things.

Q: If it's okay, maybe during this interview we can talk about some of those experiences that you drew from to think of those themes, all of those little incidents that illustrated that.

CETRON: Some of those are in this little reflection. That opportunity to speak to a thousand strangers--not strangers, community non-public-health people--with a perspective about that, really provided--not only preparing it forced me to think through the themes, but also there was a certain amount of catharsis in 00:10:00letting go of the trauma of the experience. Those were some of the bigger issues for me. On the other hand, it's quite a privilege to be in that space, as you see. I mean your job, you bear witness to story, and to bear witness to a story that intense and emotional and raw, that's a pretty powerful thing.

Q: It's been a privilege in itself. Some people went through the most intense experiences that I can imagine here at CDC, and they just continue to work here at Roybal [Campus], or--

CETRON: No matter where you were, it was hard to be untouched by the power of it because it was an onslaught in the media, the images are compelling, everyone 00:11:00could see themselves in the victims. And the inequities; the fact that the mortality rate is eighty percent if you're left there and twenty percent if you're here. There's so much you have to grapple with in that setting.

Q: No doubt.

[break]

Q: This is Sam Robson here with Dr. Marty Cetron. Today's date is January 10th, 2018, and we're in the audio recording studio at CDC's Roybal Campus in Atlanta, Georgia. I am interviewing Dr. Cetron today as part of our CDC Ebola Response Oral History project for the David J. Sencer CDC Museum. Dr. Cetron, thank you very much for being here.

CETRON: My pleasure.

Q: Could you please state, if you could, your full name and your current position with CDC?

CETRON: My name is Martin Stuart Cetron and I'm the director of [the Division of] Global Migration and Quarantine, and that's in the National Center for 00:12:00Emerging and Zoonotic Infectious Disease. I've been in this job for more than twenty years.

Q: If you were to give someone an elevator speech, just a few-sentence description of what your role was in the Ebola epidemic, what would you say?

CETRON: As the director of the Global Migration and Quarantine program, our mission is to prevent international spread of infectious disease threats, protecting in particular the American public and American interests abroad, while also recognizing and dealing with the epidemic at its source in the context of the individual victims who are suffering from this. There's this duel responsibility of preventing importation and spread, containing things at the source, and being sure that the epidemic can be brought under control as quickly 00:13:00as possible to minimize suffering and death.

Q: Could you tell me when and where you were born?

CETRON: I was born in Philadelphia, February 23rd, 1959.

Q: Did you grow up in Philadelphia?

CETRON: I grew up in Philadelphia for the early years, and then my family moved across the river to southern New Jersey for high school years.

Q: Can you tell me a little bit about those early years? What was your family like? Who made up your family?

CETRON: I'm from a small family of four. I was the oldest. I had a younger sister, two years younger. My dad and mom were both rural Pennsylvania born and raised, first ones of their families to go to college. My dad was from Lancaster, Pennsylvania; my mom from Scranton. My dad was a dentist and an endodontist after that, and he has his office in the basement of our house. We 00:14:00grew up in an urban environment in a very, very supportive family.

Q: What precipitated the move to New Jersey?

CETRON: I think my dad was moving from a general practice dentistry to a specialty in essentially, what is the infectious disease equivalent of dentistry, which is endodontics or root canals, dealing with infected teeth that needed to be managed in more complicated settings. There was a practice he was going to join across the river.

Q: What kind of stuff did you find cool or interesting when you were a kid?

CETRON: Gosh, a lot of stuff. I always liked international opportunities, travel and exposure. I was sort of a geek for science and math, and the STEM [science technology, engineering, and mathematics] fields in general. I spent a lot of 00:15:00time outdoors in the environment, and to the extent that was possible, I was always trying to get away and explore some other place, some other culture, some other group. Tremendous curiosity about humanity.

Q: Was there an early experience where you were exploring a group of people who were different from you that really stands out?

CETRON: There's a number of experiences. I was very fortunate to have these. As a young kid, I spent the summers working on a kibbutz in Israel doing agricultural work and living in a sort of communal setting with other, non-US kids, Israeli kids my age. We had a lot of raw hand, farm labor type experiences, but it was real interesting to see that society and culture where people of a similar age cohort live together, separated from their parents 00:16:00except for weekends. But also the cross-cultural activities, the exposure. It was an interesting time. I think it was the late sixties, maybe early seventies. It was a time of a lot of tension. There was war in the Middle East very close to the place where I was working. My sensibilities about international engagement, international politics, how to reconcile arguments and disputes between people on big issues, land and background, peace, religion, all these kinds of things, were really prominent. I was quite fascinated by that sort of whole setting, the milieu of living and working in that environment. And it was a place where you have to confront some pretty stark differences between people who have lots of means and people who are living and struggling more in terms of 00:17:00their socioeconomic status. A lot of the world's problems came closely into view for me and to my eyes, both from a religious perspective, a cultural perspective, a socioeconomic perspective. What was most apparent in all of that was that despite all these differences and contrasts which could be emotionally wrenching, it was easy to see a thread of common humanity in different spaces. By far, there were many more things that people shared in common than the differences that defined them.

Q: Given these formative experiences of witnessing disparities and conflict, did that influence what you wanted to do with your life? What were you thinking at that point in time?

CETRON: Oh, yeah. It was the combination of those experiences, my complete 00:18:00intellectual fascination with the sciences and medicine and the way the human body worked. I had a pretty early, strong driver to go into medicine. I wanted to be a doctor from as early as I can remember, and that was crystalized further by an experience I had with my dad who became critically ill when I was quite young, I think in high school, after returning from a trip to Mexico. He got very sick and developed liver failure and was in the hospital for months at a time. We were told he was on death's door, and none of the really talented, bright, Western doctors from the University of Pennsylvania and all these high-powered academic institutions had any idea what was making him so sick, 00:19:00what infection he got that made him so sick after simply taking a trip to our neighboring country. It was a complete medical mystery, but a very personal one. Unlike the medical mystery stories that I enjoyed reading, Berton Roueche solving all those kinds of things, this one really hit home. I think the combination of experiences I had leading up to that, and then that pretty powerful experience with my dad's illness, which gratefully he recovered from, and later was able to be diagnosed in retrospect, was probably the driver. Not only did I know I wanted to go into medicine, but I wanted to be an infectious disease specialist and I wanted to specialize in tropical medicine and understand the global picture and maybe have a better understanding and ability to intervene and control the global disease threats that had affected me so personally.

Q: It's a pretty mature career aspiration for a young kid. [laughs]

CETRON: Yeah, it was probably more rooted in fantasy than reality, but through the next thirty years I'm sort of probing for both affirming and disaffirming experiences around that. I think I was able to navigate a very circuitous and iterative path to test different aspects of that along the way.

Q: What did you do after high school?

CETRON: After high school, one of the things as I eluded to, I had this strong sense of adventure and a passion for the outdoors. I sort of drew a circle with a certain minimum distance that I needed to be from home to have a different experience and looked at schools that would be both intellectually challenging in that regard but also giving me a lot of opportunities to explore people that 00:21:00were different from me and the wilderness. I was fortunate to be admitted to Dartmouth College in Hanover, New Hampshire, in the sort of rural parts of New Hampshire. It offered that environment, which I found probably transformative in terms of my ability to create more independent thoughts, to find and build community in a small environment, to enjoy the White and Green Mountains of New England on a regular basis, to participate in Outward Bound programs in the winters in college, but also the quarter system at that school offered me a chance to spend a lot of time off campus traveling internationally. Finally, the small size and the very close relationship between the faculty and the students enabled me to get involved with a mentor my freshman year. It was Bob [Robert H.] Gross' first year as a biology professor on campus and we struck up a 00:22:00relationship in an early class I had, which continued for thirty-five years until his death. But he became an individual mentor for me and taught me molecular biology and science and genetics, and it was a really precious relationship that extended beyond Bob but to include his family as well.

Q: What happens after high school? What do you do then?

CETRON: After high school or after college?

Q: I'm sorry, after college at Dartmouth.

CETRON: After college, I'd had a number of international opportunities to study language abroad and do other kinds of things and travel extensively. The debate was Bob had always tried to convince me that really, physicians couldn't be scientists, and that I should pursue a science degree and get a PhD [doctorate of philosophy] instead of an MD [doctorate of medicine]. I think he thought if 00:23:00you really want to do science, you should get a PhD. This was a time in the seventies, so my college years were the [late] seventies, like '77 to '81, where molecular biology was becoming the science, not the tool, of genetic study. He had encouraged me to look at job opportunities with Genentech and Biogen, two big startup genetic molecular biology tech [technology] engineering companies on both coasts, one in Cambridge, one in San Francisco. I went out and had job interviews, and I was weighing--the debate between, did I want to go into medicine or science? Then I took a hard look at both my interests and my skillsets and I realized that I learned a lot in the lab [laboratory] with him over four years, but I wasn't particularly good at it. [laughter] I wanted to be 00:24:00good at it. I worked hard but I kind of sucked. I had a number of experiences that he, in his patience, he put up with me in that regard. But as I thought back, they were telling signs that I was probably better in medicine than at the bench doing basic research, and in particular that the places that I wanted to interact were at the macro level and not the micro level. Part of what was challenging for me in the research lab was working with things I couldn't see, microliter quantities of materials and molecular interactions. I really appreciated them, I believed wholeheartedly they were there, but I couldn't interact with them with that degree of precision to be good at replicating my work and my experiments. On the other hand, big picture challenges, system challenges, interactions between people and populations, culture and society, all of those types of interactions were always much more appealing and 00:25:00fascinating to me in that regard.

So I went to medical school. I went to Boston to medical school. I looked at programs that had strong infectious disease training opportunities and international training opportunities. While I was in medical school at Boston at Tufts [University], I spent a good part of my fourth year, the latter part of my fourth year studying in India, particularly in the south. These were through contacts of my mentors and teachers at Tufts who were tremendously influential people, infectious disease giants in their own right, but also had a significant amount of engagement in tropical medicine and "geographic medicine" as it was known at the time. The chance to go over and live and work and study medicine in a tropical environment like South India over several months was one of those 00:26:00really affirming as opposed to the disaffirming experiences in the lab. The really affirming experience of living, working overseas in a population-based setting, looking at problems like leprosy and other tropical infectious disease issues, was tremendously influential and in some ways transformative.

Not only did I fall in love with tropical infectious disease and had a whole world of experiences to draw upon, I fell in love with Indian culture and tradition and rituals and practices and understandings. I left at the end of fourth year, graduated from Boston, and went to the University of Virginia to do internal medicine for three years of training. I think in my first rotation on 00:27:00the wards, I met and fell in love with an Indian woman who I later married after a number of years, and we have sort of blended our cross-cultural backgrounds between her Indian story and my sort of Eastern European Jewish narrative into this Hind-Jew, we call it, [laughter] exposure. Maya, who's been significantly the most important person in my life over the last close to thirty-five, forty years, has not only shared some of those interests and passions that I have, she was a nurse on the wards. I was on my first rotation, which was oncology. I had a really sick cancer patient. She was a specialist in nursing cancer patients, and I was a very green intern. I had just had all these months of experience processing my time in India, so not only did I fall in love with her beauty and 00:28:00mystique, but she was an intellectual powerhouse and knew a lot more about what she was doing than I did at what I was doing. We combined to be a team, and she really taught me how to care for cancer patients beyond just the science of that. How to draw up and deliver chemotherapy, how to listen at the bedside, and a lot of her intuition, a lot of her skills, a lot of her cultural background that led her to be such a fantastic nurse were really formative.

At University of Virginia, I ended up staying in Charlottesville with her and in the program for three years of internal medicine, then a year of emergency medicine on the faculty, but continued to pursue my--and the University of 00:29:00Virginia had a really, really strong tropical infectious disease program and wonderful mentors for me to draw on there. I had a chance to work and study and live abroad in Brazil for a number of years through the UVA [University of Virginia] program and began to meet other people with similar interests who had made careers that were about ten years senior to me. Really influential people: Dick [Richard L.] Guerrant, Dick [Richard D.] Pearson, many others on the geographic medicine department at UVA, had active work going on in leishmaniasis and diarrheal disease and all sorts of tropical infectious diseases. Again, another really strongly affirming experiencing, Brazil being very different from India in some respects, but understanding culture, community, population, engagement, circumstances, and falling in love with parasitic infectious 00:30:00diseases. I spent a lot of time working with Leishmania and Chagas disease, two parasites that were spread through a variety of vectors. I became totally fascinated and enamored with that part of the science of medicine and the pathology and the interaction between pathogen and host and the environment, and that all three of those things, that sort of holy trinity of infectious disease, that really took a strong grip for me.

From there, I was looking to have deeper professional and specialty understanding of infectious disease, and I went to the University of Washington to do a fellowship in infectious disease and took my experience and contact and exposure in Brazil back into the lab again to do some basic immunology research 00:31:00on Chagas disease, looking at the host immune response to this parasitic infection, to Trypanosoma cruzi, which once people were bitten by the reduviid bug and the parasite was injected into the body, it persisted there for life through some very clever interactions with the host's immune system, often in low level. But then it created an immune response in the host that was an autoimmune response that was destructive against host tissue, and our research project was to understand this concept of autoimmunity with regard to this parasitic infection. It turned out that we discovered an antigen on the flagellum of this parasite which mimics nervous tissue in humans. When the body developed an immune response to try to get rid of the parasite, it was also developing an immune response that attacked the nervous tissue in the heart, which makes the conduction system work, and the nervous system in the gut, which 00:32:00makes the GI [gastrointestinal] tract work. As a consequence, patients with chronic Chagas disease go on to get cardiomyopathy, a heart problem, and their heart dilates and it doesn't pace properly, and they get megacolon or mega GI tract, and their intestine doesn't move and peristalsis doesn't work properly.

My role in all of this, the lab I was working in with Wes [Wesley C.] Van Voorhis at the University of Washington, was looking at the molecular interactions. As probably has become obvious by now, I was much more interested in the population-level interactions. I was working to set up a field program to find chronically infected Chagas patients, those that had heart disease, those that had GI disease, and those that had no apparent disease, and try to contrast what was different about them and their bodies and their bodies' response to the 00:33:00parasite and see if we could sort out what drove some people to get heart problems and some to get GI problems and some to just keep everything in check with no apparent problems. We set up a research lab in northeastern Brazil, in Fortaleza, with the University of Fortaleza and some partners there, and enrolled people from all over the northeast that had chronic Chagas disease. We drew their blood, we separated their blood cells out to find their immune response, their immune cells, their lymphocytes and peripheral blood mononuclear cells, and we exposed them to different stimuli with some of the antigens that we were discovering in the laboratory at University of Washington and tried to assess in a Petri dish their immune cells' different responses to these antigens that we thought were triggering. That was sort of a four-year project between doing clinical medicine in Seattle. I would also do clinical ID [infectious 00:34:00disease] ward rounds at the university hospital in Ceara. Sao Jose Hospital was the infectious disease hospital in Ceara, and several really influential clinical mentors taught me a lot about tropical infectious disease. Anastacio [de Quieroz Sousa], who I recall very fondly, ran the hospital of Sao Jose, and I would do ward rounds for him when we weren't doing the research work. I fell under a mentor from the University of Virginia who was a brilliant pediatrician that was working in diarrheal disease named Jay McAuliffe. He was the director of Project Hope. Later on when Jay's Project Hope tenure was over, I recruited Jay to CDC, to come here, and I lived with Jay and his wife, Bell, in their 00:35:00house through the birth of both of their kids. I would live with those guys, see patients with Anastacio, and do research on Chagas disease. It was a pretty great life.

Q: It sounds incredible. What years were these again?

CETRON: I think '89 to '92.

Q: Okay, finishing up in 1992.

Q: That's when I had to decide, where was all this going? It was pretty clear to me that I liked clinical medicine, I enjoyed patient care, especially patient populations that were different from outside--either people who had traveled to those places and gotten sick with things that no one knew about, which harkened me all the way back to my childhood days and my father's experience, or working with the diaspora populations of immigrants and refugees who were born elsewhere and then had moved to the US to various places and needed someone who understood 00:36:00the infectious disease issues in those communities. I was involved in working in, and in some cases, running the tropical infectious disease clinics at these other training places along the way. When I wasn't in Brazil doing tropical infectious disease onsite, I was doing it at the University of Washington in clinics there that dealt with travelers, immigrants, refugees, migrant workers, etcetera. Really, really rewarding. As a result of that, we often made diagnoses that were pretty rare in the US and many of which didn't have treatments that were readily approved or available in the US. They required orphan drugs, which weren't fully approved in FDA [Food and Drug Administration] because they didn't have a huge market here.

That's when I first had my interactions with CDC. I would call up the CDC Drug Service, which kept a supply for investigational use of these orphan drugs to 00:37:00treat exotic infectious disease. I first met some people in the Division of Parasitic Disease through that process. Ralph Bryan was an early mentor of mine. He was a CDC medical epidemiologist who had gone through EIS [Epidemic Intelligence Service], and he was overseeing the clinical approval process for the Parasitic Disease Drug Service. I'd call up on a pretty regular basis and talk to Ralph and say, "I've got a patient with Chagas disease from here," or "I've got somebody with leishmaniasis cutaneous, mucocutaneous from Brazil," or "somebody with leish from India, and we need some consultation and support for treatment strategies." I was just blown away because I probably had naively thought that I knew something about these compared to some of my colleagues in 00:38:00academia. [laughter] When you're in that setting and you've got that experience, people will turn to you as the expert on that problem. But in reality, my knowledge of this field could fit in a thimble compared to the people I was consulting with at CDC. I was pretty blown away by the depth of understanding, expertise, commitment, and the challenge and passion for what seemed to be a pretty narrow space of interest for most US physicians. But there was this whole program at CDC, the Division of Parasitic Diseases, which was filled with brilliant people of all sorts: PhDs, MDs, veterinarians, and they knew stuff about this that was just beyond the pale. It was fascinating, the depth of understanding, the appreciation and commitment. As I said, I at times thought I 00:39:00had a fair amount of experience, but nowhere near it. I was totally enamored with the interactions that I had here. Then one day, as my three years of fellowship training was ending, Ralph said, "What are you doing next year?" And I said, "I don't know. I'm interviewing for faculty positions, I'm interviewing for ID practice positions." But I said, "This is who I am. What I really like is population-based medicine in developing country settings, and I'm more of a big picture person than a bench scientist. I love clinical practice and patient care, but I really feel like I want to get at the root cause, the system base root cause of some of these issues." He said, "You belong at CDC, you belong here. You should come here. Have you heard of EIS?" I said, "No, what's that?" "Epidemic Intelligence Service." Boy, it had a great ring and appeal to it. Ralph convinced me to look into it, and the next thing I knew I was applying to 00:40:00the EIS program and learning about how to be an epidemiologist. Because one of the challenges in typical medical education for me at that time was there weren't a lot of role models that I was aware of, or exposed to, that had actually studied the epidemiology of infectious disease and tropical medicine or the factors that go into driving an epidemic. There were a lot of people who did individual clinical patient care, and there were a lot of people who did bug-specific research at the bench in infectious disease. But there weren't nearly as many--and admittedly, this was thirty years ago or so--that really understood the epidemiology of infectious disease, that appreciated that interaction between pathogen, host, and environment, and could define it, 00:41:00describe it, characterize it, and once having that appreciation, get involved in influencing the trajectory of epidemics or understanding the cause of epidemics. He convinced me pretty easily that EIS was the right next step, and I came to CDC in June of '92, and I've been here ever since.

Q: Did you place immediately in [the Division of] Migration and Quarantine, or what happened?

CETRON: There was no Migration and Quarantine then. It was a very interesting thing. I came actually thinking, somewhat naively, that I was just coming--if I could get into the program, I was just coming to work with Ralph. Then I realized as I learned more that EIS was a broad program. You interviewed and you went to a match and then you got to a program. Fortunately, in the end, I did end up with the Division of Parasitic Disease, and Ralph was my supervisor for those two years. But it was just the beginning of understanding things.

I did EIS '92 to '94. After that it was pretty clear that I wanted to stay. My wife was actually going to stay in Seattle at the time, she had a great job. She had switched over from critical care and hematology-oncology nursing and bone marrow transplants at the university to doing public health work at Seattle, King County. We had bought our first house, she was very settled, and she said, "You're going to go to do EIS for two years, you're going to be traveling all over the world, and there's not much for me, so I'm going to stay here." And I said, "Nah, we should try something together." We talked it through. She applied to Emory [University] to the MPH [master of public health] program, and she spent the two years getting a master's degree and I spent the two years in EIS. We kept our house in Seattle with the full intent of going back, but we both really fell in love with what CDC had to offer. I did parasitic disease for a 00:43:00couple of years. At the end of that, my first child was born, and it was clear that we were going to stay. I was offered a job to deal with a new, emerging problem in antimicrobial resistance, and so I joined Rob [Robert F.] Breiman's group in Bacterial Respiratory Diseases. I worked on setting up the surveillance systems for drug resistant pneumococcal infections and other drug resistant bacterial infections. Another set of tremendous mentors--Rob Breiman, Anne Schuchat, Jay Wenger, Claire [V.] Broome--some of the CDC legends and greats that were available to learn from and learn with. It was a fantastic experience where I really cut my teeth doing both surveillance science and outbreak 00:44:00control, outbreak investigation.

I did that for two years, and these years between '92 and '96, those four years, were a really seminal time in infectious disease at CDC because this whole concept of emerging infectious diseases was unfolding. The Institute of Medicine issued a report led by Joshua Lederberg in 1992 called "Emerging [Infections: Microbial Threats to Health in the United States]," and highlighted the major drivers of these sort of emerging and reemerging threats. Population growth, urbanization, climate change, travel and trade were a huge part of that; genetic evolution of microbes to become resistant was another part of that; conflict and civil war and strife and population displacement was a big part of that. All of 00:45:00these really big ecologic issues that for me, harkened back to this holy trinity of pathogens, hosts, and environment being so critical to understanding the macro picture of what we were seeing in terms of epidemic control and infectious disease. To their brilliant credit and the brilliance of Josh Lederberg, Nobel laureate, really articulated and saw this big picture. By happenstance, Ralph Bryan, my EIS supervisor, was one of five people who the [National] Center for Infectious Disease director, Jim [James M.] Hughes, identified to write CDC's response to the IOM [Institute of Medicine] report. Through Ralph, I got to actually engage in that process of laying out, what should CDC's strategy and response to emerging infectious disease, how does that shape? What are we going to do? If this is the picture, what do the next ten, twenty years look like? 00:46:00Together with Ruth Berkelman and Bob [Robert] Pinner and Ralph Bryan and Bob [Robert] Gaynes, those five really led the charge on this. Being an EIS officer with Ralph gave me the opportunity to weigh in and help add some ideas and contribute some thoughts to that process.

In '96, one of the bigger issues that we came up with in that CDC response was the creation of sentinel provider networks. Realizing that emerging infectious disease threats really had to call upon beyond just the public health community for a response--that the clinical community, the academic community, lots of people had to be woven together in tighter networks to create a more comprehensive knowledge base about what was going and where. This was right up 00:47:00my bailiwick. Two of the four original sentinel provider networks that were proposed were ideas that I had. One was creating an international travel tropical medicine clinical network where we would basically recognize that international travelers and immigrants, refugees and migrants who were crossing geography, they were also crossing epidemiologic divides. They were coming from places where burden was high and science and diagnostics were lower, to places in the West where the burden was lower, but the capability for detect, prevent and respond was higher. The idea of this network was to weave that together to see travelers as sentinels for what might be going on in silence or hidden in other parts of the world. This was sort of a perfect fit--I had been working in 00:48:00travel tropical medicine and migration clinics since I was a medical student, and I knew that each of our clinical experiences was rich and interesting, but the sample size was too small to actually weave that picture together. One of the first things I did when I came here in '92 was work at Emory with Phyllis [E.] Kozarsky in the travel and tropical medicine clinic there, as a result of this response of sentinel networks, that we really needed a sentinel network that could link clinics like Phyllis' clinic, like the clinics I worked in in Seattle and in Virginia and all these other places. The data from all those clinics should be tied, the diagnosis and the itinerary and the source of exposure and the timing should all be tied together into a global network. That network became GeoSentinel in 1996, was funded, and I was sort of building and 00:49:00working and trying to craft that as a global surveillance network.

The other global surveillance sentinel provider network we talked about, again, harking back a little to my early childhood days and my dad's experience in Mexico, was the huge percentage of the foreign-born population in the US that was actually Mexican-born, and the world's busiest international border was the US-Mexico border. Our sister countries were tightly woven together epidemiologically, geographically, and in some regards, culturally as well. Yet there was still a big void on what surveillance happened across the border. We created another network together with Jay McAuliffe, who now had been recruited to CDC; Steve [Stephen] Waterman, who was a state epi [epidemiologist] for California and a former EIS officer; and we created something called BIDS, the 00:50:00Bi-national Infectious [Disease] Surveillance system, initially the Border Infectious Disease Surveillance system. We took advantage of local, city, state and federal partnerships in public health along the border zone to create a sort of shared epidemiologic unit and prioritize certain diseases with common case definitions for shared surveillance.

There were four sentinel provider networks that were proposed in CDC's response to emerging infectious diseases: an ER [emergency room] network; an IDSA [Infectious Disease Society of America] network, which Bob Pinner had sort of come up with and led on; and then the GeoSentinel global tropical medicine network and a BIDS network, which I had taken the lead on. These were maturing and being birthed around '96.

Then another one of these great, sort of fateful accidents happened. Jim Hughes, who was the director for the National Center for Infectious Disease, who I also 00:51:00credit as being a critical mentor and a wise, prominent leader in infectious disease for me, had taken the somewhat defunct Foreign Quarantine Service that had been sitting in the Center for Preventive Services, another place where the TB [tuberculosis] program was, and it sat there pretty much dormant from 1967 when it came to CDC until about 1996. When David Sencer came over in the sixties and was consolidating, he pulled the Foreign Quarantine Service into the agency, but there's a famous surgeon general quote that said, "the war on infectious disease is over" in the late sixties, and that we don't need a Foreign Quarantine Service in that regard. We're eradicating smallpox, antibiotics are 00:52:00being discovered rapidly and they still work, childhood immunization programs are taking off eradicating measles, mumps, rubella, etcetera, etcetera, and we're winning. We've got this one, it's a wrap--which might have been absolutely true in 1967, notably before the era of jet travel, before the era of [high-speed] planes and before all the drivers in emerging infections. The Foreign Quarantine Service was essentially dismantled in the late sixties, sat quietly with a handful--probably less than a dozen people. And in 1996, Jim Hughes had the Foreign Quarantine Service back in the National Center for Infectious Disease. He approached me and a couple of other people--Bob [Robert B.] Wainwright, who was a division director in the Artic Investigations Program. He knew that I was particularly interested in this space of international 00:53:00migration, immigrant, refugee, migrant health, in setting up global tropical surveillance systems, tropical medicine clinics linked to shared data. And I was very attached and wed to the challenge and the problem of emerging infectious diseases. The opportunity came up to be part of the rebuilding of the Foreign Quarantine Service, which had a several hundred year history; to be reinvented as we went into the twenty-first century with a whole different set of threat pictures. Global migration became an entity that needed to be studied and characterized. The movement of people, animal and things was fundamentally different in every way: speed and volume, moving from sea-based travel to jet air travel, where people and pathogens and things could move around the globe shorter than the incubation period of most of those threats. Which meant that the idea of quarantine, which was established formally in the fourteenth century 00:54:00during the Black Plague epidemic, was that you hold the ship out of port for forty days and by doing that the pathogen burns out. Whoever survived is lucky enough, they get let in and fumigated, and that's your defense against importation and spread. It worked in the fourteenth century through maybe perhaps the nineteenth and early twentieth century, but it wasn't going to work in the twenty-first century, and it needed to be fundamentally redesigned. That opportunity came up for me in '96 when I moved from the Division of Bacterial Diseases to a new Foreign Quarantine Service, which we reinvented and called the Division of Global Migration and Quarantine, and I've been there ever since.

Q: Gotcha. That's a brilliant little summation of where you guys came from.

CETRON: Perhaps not so little, but it is a summation. [laughter]

Q: True.

CETRON: It's been a great ride in that regard because it offered an opportunity to rethink on a level that I like to engage is big, system level thinking, looking at macro-level problems and trying to figure out what systems can be reengineered and designed for surveillance so that we can detect threats early for prevention, so that we can intervene. And for response so that we can more effectively respond in ways that are cognizant of this trinity of pathogen, host and environment and all those interactions.

Q: What kinds of progress did you make in the first few years?

CETRON: Well, we matured these systems like GeoSentinel and BIDS and successfully were able to get funding and grow them widely internationally. We had good surveillance systems. We started developing datasets that would define 00:56:00the movement patterns. We started across government and non-governmental entities that had access to movement data. We needed to basically define the migration of people, animal, and things, and there were datasets out there, but they were locked away in a narrow silo of special interest space. I wanted to be able to get those datasets into public health awareness. So we worked with the airline industry and were able to capture International [Air] Transport Association, IATA, data of all the international air routes by airport. What volume was leaving from A and going to B. We were able to do similar things with the cargo and with animal shipments and with all sorts of exchange of trade. We started looking at the challenge of defining the epidemiology of movement, and we built out a number of systems to not only curate them and anchor them in time 00:57:00and place and update them, but also to integrate them with other systems. We were developing surveillance systems for disease burden and looking at other projects that had mapped disease burden by geography. And then we were developing these movement databases by air, land and sea, border crossing datasets and airplane datasets and rail and cargo movement datasets and things like that. Looking into shipping records of what was coming in as imported animals, from where and what threats did they potentially represent as they were translocated across these epidemiologic divides.

We began a project that was conceived more than a decade ago called BioMosaic, which was a project of being able to look and integrate multiple big datasets that are all sharing a common factor of a GPS [global positioning system] location at the most granular level and a timestamp. If you had time and place, 00:58:00which was just a fundamental epidemiologic principle, if you could get who, what, when and where linked together across these big datasets, you would suddenly have that picture and be better able to anticipate, if something emerged in A, was it likely to go somewhere? If it went somewhere, where would the next stop be? If it arrived at that next place, in whom would it be arriving? What type of person? If it arrived in that person, what's the likelihood of it finding fertile ground and soil in terms of spreading? That was the challenge that we were starting--we wanted to build out that picture. We wanted to be able to forecast around emerging infectious disease by moving back the clock. We wanted to understand what the risk of a threat, where something was likely to emerge based on these environmental factors, the overlap of pathogen, host, environment, temperature, vector, disease, those kinds of 00:59:00things, social interactions, disruption, and then say, what would be the trajectory of that pathogen likely moving somewhere else? Where would it go? It turns out, although the US may not be the place that most things will emerge from, we don't have as many of the drivers exactly here for new emergence compared to say Southeast Asia or places on the Africa subcontinent because of the interactions between humans and animals, between the sort of contextual setting. Because we are so highly connected as a country, maybe the most highly globally connected country on the planet, we would likely be the next place it would be seen. And it's possible we would be the first place that it was diagnosed in terms of with the public health infrastructure and the tools and capacity we have.

This idea of building an international network, understanding movement of people, animals and things and travel and trade, protecting the homeland from a 01:00:00classic quarantine regulatory mandate, but also understanding, what is actually going on in a shrinking globe, and where do we need to apply public health tools at the source? This really became the focal mission of our program. We just started adding--I think in '96 we had maybe a dozen people, the number of quarantine stations had been reduced dramatically in the late sixties as I mentioned, and we started adding them strategically. We elicited support from the Institute of Medicine with Jim Hughes fervently behind this rebuilding process in order to develop a more robust strategy for twenty-first century threats. This was driven by the recognition that there were potential threats not only from Mother Nature, but also man-made threats in terms of use of biologic weapons, potentially insecure stocks of dangerous pathogens like 01:01:00smallpox as infrastructure was falling apart in certain places. Being able to do these types of anticipatory response plans really required thinking about this globalized picture, thinking about globalization and its contribution to the infectious disease threat and the health security, not only of the US, but the health security of the globe. That became sort of our anchoring point, and we grew the program out of the dust shells of 1996 into a program that was more able to respond to the kinds of threats that we have seen since that time. Learning from the anthrax attacks and then SARS and then monkeypox introduced through this bizarre thing, which basically, giant Gambian pouched rats from one 01:02:00place move into the exotic pet trade and are cohabitating with prairie dogs sucked up out of holes in their habitat in the [American] West and spreading monkeypox from pouched rats from Africa to domestic prairie dogs exported to Japan and to pet stores all across the US. That story is the story of emerging infectious disease in the twenty-first century, and our program was just beginning to be better poised to be able to define that problem. We were defining it horizontally while at the same time collaborating with and engaging heavily with this deep vertical expertise of programs that were pathogen-specific around the agency. We were looking at the populations and the movement and the trajectory and the interactions and the sort of social milieu, and Inger [K. Damon]'s group was looking at the specific high consequence pathogens, or somebody else's group was looking at the bug itself, and we were 01:03:00bringing a better understanding of who the hosts were and what the environment of movement and exchange was. That, for me, was so satisfying: to be able to round out the deep vertical expertise and pathogen-specific expertise that exists at this agency almost unparalleled to anywhere in the world with this newly appreciated, almost socio-anthropological framework in which all of that was occurring. That was like, what I had been dreaming of since I was a kid.

Q: I really like that image that puts in my head of the horizontal and the vertical ways of understanding the spread of these diseases. Were there some early--was it always smooth when you were trying to integrate those?

CETRON: Never smooth.

Q: Never smooth?

CETRON: Never smooth, right. And not because--you know, the friction doesn't come necessarily from turf battles. There's the usual stuff of who's in whose 01:04:00space. That's not so much of the things that leaded to rocky--to make the road a little rocky. Part of it is that some data is understood or known, but it's only known in a narrow context, and some of the horizontal stuff are data that needs to be acquired from a variety of sources, some of which are dated, some of which are updated. Some of which come with a large margin of error and uncertainty and sampling bias, and some of which are really systematically collected. Some of which are hard to get because people don't want to disclose things around national origin or census data, which richly has country of birth. Public health data is not always as richly informed around some of these variables because of the consequences of stigma or legality or status or these other things. It's really important for public health to have access to that information to be able 01:05:00to define it epidemiologically, but it's really important to be able to use it appropriately as well. The challenge is really about building the horizontal warp on this in so many ways in the public health sphere from scratch. It really didn't exist. Finding quality transportation data was really hard initially. Now we've gone through the process of curating it, we have other systems to define it. Really identifying who's moving and how and in what time frame. Sometimes it's easier to know who comes in than who goes out of the country. These types of things. We were early when we were trying to do this in the mobile device arena, which positioned people. Now we have better tools to define that mobility, but we still face these issues around the privacy struggles. How do you responsibly use identifiable mobile information, de-identified to protect it, but still identified enough to have an appreciation of who's moving from 01:06:00where to where and when? Those are big social issues, big privacy issues, big considerations. The rockiness around this.

Also, updating the regulatory framework. When I came into the program in '96, the quarantine regulations hadn't been substantively revised in more than fifty years. We were still dealing with a whole set of stuff on the books that represented a threat picture from the eighteenth, nineteenth, and early twentieth century, but not a threat picture that was commensurate with the twenty-first century pathogen emergence. We had to go through this huge regulatory process to revise that. There were a lot of vested interests that were willing to--we had to do contact tracing on airplanes of people who were exposed to pathogens while they were on the move, but then quickly scattered. It wasn't always easy to get that information captured and find people, and you 01:07:00have this narrow window. If you've got somebody exposed to SARS on a plane and it's got a high consequence of killing them, and when they get sick they are likely to spread it through respiratory means to other people, you need to find them quickly, be able to isolate them, identify their contacts, potentially monitor all the contacts and the tracings for a period for symptom onset, and offer something in exchange for cooperation in order to prevent spread. And you have a narrow time window to do it. With something like a pandemic of influenza, you have an especially narrow time window where people can spread either twenty-four hours before they even manifest their first symptom, and by two days later, they're already fully contagious. That's an epidemic that will rapidly escalate. Being able to efficiently put together the datasets that are needed for this type of contact tracing, movement, monitoring, all that stuff, is 01:08:00pretty challenging. It's not been smooth, but we've been deliberate and persistent and have taken advantage of the fact of these rapidly ensuing global emerging threats to not only make progress in dealing with that epidemic at that time in that setting, but take advantage of the lessons we have learned, the gaps that existed in trying to do that job and closing that gap before the next emerging pathogen comes along.

Q: I'm interested in some of these lessons that were learned from '96 up until the time of Ebola. What's particularly interesting to me is the idea of the vested interests and trying to get data from someone like an airline, for instance, on passenger data, when that airline might be reluctant to give up that passenger data. Or, I don't know, I'm sure that there are tons of other examples.

CETRON: Oh there are, yeah, lots of stories like this.

Q: Do you have any specific examples you could point to where you said, from this interaction, we learned this about dealing with interests?

CETRON: I would say from all these interactions, what I've learned is the importance of balancing the interests of containment and control with the interests of compassion and care and respect at the individual level. What I've learned is that these aren't dichotomies--they aren't either/or premises. If you go into these engagements with this idea of, I have the right and the power, and in order to control this, this is what we're going to do, and you have to give me that data and information, when the perspective on the other side is, I've got interests that need protecting, whether they are privacy interests around the individual, whether they are business interests, whatever those are, you need to be able to respect that. No, in confrontation, I'm not going to give you 01:10:00that. I'm going to look at all the legal means that I can withhold, and you're going to look at all the legal means that you can force it and compel it, and most of it ends in a standstill. Coming to truly appreciate that these are false dichotomies, that there are ways to find the overlap of those Venn circles, those Venn diagrams, there's a huge amount of overlap where it's in the individual's interest, it's in the company's interest or the private sector's interest, and it's in the public interest for us to be cooperating. That actually, everybody can win and that you don't have to have either control or care, you can have care and compassion and control and containment living in the same space. Most of it is about finding where that intersection is. And also, being mindful that you want to be playing in that intersecting space in the least restrictive means that you can in order to accomplish your objectives. If you can accomplish something with a voluntary request with ninety-eight percent 01:11:00compliance and no need to bring in legal and law enforcement and all these other compelling approaches, but you can make an argument voluntarily, which also is in the interest of the individual, the victim, as well as in the interest of the community at large, then why issue an order and create a conflicting situation or a confrontational situation? If the disease can be contained with something short of one hundred percent compliance, don't have to go for one hundred percent compliance, go for voluntary and build goodwill, build trust. Because the building of the goodwill is going to go so much further than the bankruptcy of trust will. That lesson has played out for me over and over in so many ways, in so many times. I think that's really clearly true, avoid the sense of these false dichotomies.

When I look at the job--and the director of the quarantine program has the largest regulatory responsibility at CDC. It's atypical for this agency to have regulatory responsibility, it's often more a technical agency, but it inherited that when it inherited the quarantine service fifty years ago. The questions that come with those kinds of responsibilities for me, the ones that are obvious when you have regulatory program is about authority. What's my legal authority in this space? May I do this? Is it permitted? Another question that you come when you start thinking about that is, what's my capacity to implement these regulations? Do I actually have the resources and capacities? A lot of times, I think, regulatory programs get stuck on the may I and can I, and they don't ask the third question, which is the most important question, which is, should I do 01:13:00this? Is this the right thing to do in the spirit of epidemic control? In which case, the regulation just becomes another tool for prevention in terms of looking at the epidemic. It's not the endpoint in and of itself. It's not simply having a regulation to have it or having an authority to enforce it, it's the, should I do this. Once you ask that question first--what should we be doing--then you can go back and say, do we have permission to do it and if not, is there a way to get it or does somebody else have permission that we can leverage to do it? If we don't have the capacity, but we need to be doing this, then what do we do to find partners to grow this capacity? How do we get that? By putting that question first, which I think is the fundamentally most important question, you get down to other aspects of should. If yes we should, and then we can figure out we may and we can, the next question is, how do we do this in the least restrictive means? How do we implement an ethical quarantine 01:14:00program that respects individual rights while concurrently protecting the public at large? Every big epidemic that I've been involved in at CDC has been an epidemic of disease followed by an epidemic of fear and an epidemic of stigma. Any time we try to approach only one of those, we miss the opportunity for a healthy response. We have to be doing what we know technically to control the epidemic of disease, but if we miss the epidemic of fear that's going on among the non-affected and don't address those concerns, or we miss the epidemic of stigma that's turning victims into vectors and stigmatizing and marginalizing, we drive surveillance and reporting and cooperation and all the voluntary measures you need to get things under control, you drive that completely underground if you stigmatize and dismiss people and see them as vectors rather than victims. This balance, this tension of, how do you have an ethical and a 01:15:00successful and effective isolation and quarantine program? How do you prevent against importation and spread while minimizing the impact on individual liberties, trade and travel, all of those things? Instead of seeing them as the dichotomy in which they are often presented, "we've got to build this, we've got to lock it down, we've got to have a full-on quarantine containment and that's the only way to do it," and that's usually not true. Usually, what's true is we need trust and cooperation, we need engagement, we need multiple partners, and we need to find the areas of the Venn diagram where the individual's interest overlap with the interest of society because they're there and they are substantial. Holding the "both/and" rather than the "either/or" in this process is just a paramount principle.

Q: I want to thank you. I think that we won't have enough time to get to Ebola if that's okay with you.

CETRON: Yeah.

Q: Would you be willing to come back if you had--

CETRON: Sure, we can talk about Ebola later.

Q: Okay, I know you have a crazy schedule.

CETRON: No, that's fine.

Q: But I think that actually is a brilliant place, that I think we've set the stage now to be talking about what happened in this one particular incident starting in 2014.

CETRON: Okay sure, it's been very enjoyable sharing these ideas with you.

Q: It's been very enjoyable listening.

CETRON: All right, I'll see you next time.

END