Dr. Mary Choi

Dr. Mary J. Choi

Q: This is Sam Robson here today with Mary Choi. Today's date is May 24th, 2016, and we're here in the CDC [United States Centers for Disease Control and Prevention] audio recording studio at the Roybal Campus in Atlanta, Georgia. I'm interviewing Mary as part of our CDC Ebola [Response] Oral History Project. Mary, thanks so much for being here with me today. For the record, could you please state your full name and your current position with CDC?

CHOI: It's Mary [J.] Choi, and I'm a medical epidemiologist with the Viral Special Pathogens Branch.

Q: Great. Can you tell me when and where you were born?

CHOI: I was born in Seoul, Korea, on January 24th, 1973.

Q: And where did you grow up?

CHOI: I grew up in a suburb of Chicago called Skokie, Illinois.

Q: What was that like?

CHOI: I think it was pretty typical. Suburban neighborhood, kind of a normal John Hughes movie. [laughter] They're all based on Illinois.

Q: What did your parents do?

CHOI: My father was a city bus driver for the city of Chicago and my mother eventually ended up working at the post office.

Q: Was it just the three of you in the household?

CHOI: No, actually, I have a younger sister. So just the four of us.

Q: What kind of stuff were you into back then? Up through high school, let's say.

CHOI: Growing up, we're all into adventures. My sister and I and our friends would make up adventures and different kind of quests that we had to complete within the two-block radius of our house because we couldn't go that far. I think we were always trying to look for adventure and adventuring and doing 00:02:00kinds of scavenging, hunting kind of stuff. Just typical.

Q: Did you have specific areas that you were drawn to in school?

CHOI: I don't really think so. I don't know that I took school too seriously until I got a little bit older. I was always interested in science, but I don't know that I was the most applied student when I was younger.

Q: What did you imagine your future to hold?

CHOI: When I was little, I was going to be an astronaut. I really idolized John [H.] Glenn [Jr.] and that sort of thing. But as I grew older, I thought going to space would be awesome for me, but I didn't really see how that would really impact other people's lives, per se. So I tried to find a field where I could 00:03:00have more of an impact on other people's lives.

Q: Got interested in helping other people?

CHOI: Essentially, basically. Very cliche-ish, but yes. [laughter]

Q: What happens after high school?

CHOI: I went to college at Boston University. I was a human physiology major, but then I also liked literature and that sort of thing, and so I ended up being a double major in human physiology and Greek and Roman literature, which was really kind of a nice balance. When I got tired of studying the human body, I would read stories, which is kind of fun.

Q: Yeah. I imagine that with the terms, etcetera, there was probably some cross-pollination between the two.

CHOI: Yeah, it's pretty interesting. It's fun to study something completely 00:04:00based in science and then read something in the literature that kind of reflects on the science, but from a different perspective. I found that really fun.

Q: What happened after that?

CHOI: After college, I--what did I do? Oh yeah, [laughs] I went to med [medical] school at George Washington University in [Washington], DC. I spent four years there, but GW was one of the most expensive medical schools at the time, and so after my first year of med school--well, for my first year of med school I had to sign a loan check for, I think it was like forty thousand dollars. I thought to myself, I need a scholarship. But there aren't that many available. There's one if you can commit in your first year of med school to going into primary care, but as a first-year med student I couldn't commit to that kind of thing, in which case your only real options are in the military. There's army, navy, 00:05:00and air force. Air force is the cushiest life, and their deployments are pretty short, but I missed the deadline, so I couldn't apply for the air force. Then the navy--you have to pass a swim test, and I couldn't swim at the time. So I'm like, army it is! [laughter] I applied for an army scholarship and I got it, and they paid for the next three years of med school, and then as an obligation I was going to serve--I had to serve eight years total.

Q: How did you decide to go to med school in the first place?

CHOI: It's weird. I don't really know, and actually, I do remember this moment when I was in junior high school where my parents actually said, "We were thinking that you would make a good pediatrician," and I told them there's no way on God's Green Earth I would ever be a doctor. Because it's too long, you 00:06:00study for too long and that sort of thing. And I'm pretty good at just not doing what my parents tell me. It's pretty surprising that I actually went to med school. They may have actually used this as a technique, you know? In retrospect, it might have been their way of getting me to be a doctor. I don't know. It's weird. I don't know that there was a moment that I can recall really where I thought to myself, yeah, for sure, I'm going to be a doctor. But once I did decide, I knew that I wanted to be an emergency medicine physician.

As all high school students who are interested in going into medicine do, they volunteer at the hospital. You don't do anything particularly taxing--like change sheets on a gurney or something like that. I remember working in the ER [emergency room] and changing sheets in the gurney, and they were expecting a 00:07:00trauma. It was a motorcycle accident. I remember thinking, oh my gosh, I am so nervous and I'm not even involved in this person's care. I'm like, oh, they must be kind of nervous. They don't know what to expect--how sick is this guy, whatever. I thought to myself, well, if I'm going to be a doctor, I never want to be afraid of what will come through the door. Emergency medicine really is that kind of medicine where you basically are trained to treat whatever comes through the door. So once I did decide on medicine, I pretty much knew I was going to be an ER doctor.

Q: After med school, was it then immediately to the army, or did you have a residency?

CHOI: When you're in the army, you have to apply for an army residency. Then you also have to apply for a civilian residency. I didn't want to go to an army 00:08:00residency. The problem was that when you're in army residency, you'll go in for one year and then after that you have to reapply to stay in. But the thing is there are a lot of doctors who've only had one year of residency and then have been sent out to work in a clinic. All those people are reapplying--are applying for your second-year spot, and I didn't want to interrupt my training. I didn't want to train for a year and then go out. I didn't feel like I would know enough to do that. And then, the process is that not only do you apply, but if you're interested, you call the army residency and you ask them for an interview. Then you pay for yourself to go out to this interview. I thought, I don't want to go. Why would I pay money to fly somewhere to an interview for a residency I don't want to go to? I actually applied because I had to, but then I never scheduled 00:09:00any interviews because I figured that's kind of a surefire way of not getting into an army residency. And it did work. Though I've heard that the army has caught onto this, and so what they'll do is they know you want to do ER, and they'll take you into a psychiatry residency or something like that. But anyway, it didn't happen to me. They were as eager to see me as I was to see them at the time. I ended up doing a civilian residency at the University of Michigan, and then after that, I entered active duty and they sent me to Germany.

Q: Did you go through basic training and everything too?

CHOI: Yeah. After residency I spent, I can't remember, I think one to three months in San Antonio, Texas, doing officer basic training, which is kind of a weird thing because you have grown adults who are in their thirties who have 00:10:00been living their lives a certain way, and then you put them all together and then you tell them how to shine a shoe. Or how to line up, or how to show up somewhere on time. It was an interesting experience, but you make a lot of really, really good friends.

Q: Any other specific memories of that time?

CHOI: It was kind of weird. We were all like normal people, and then we joined the army, and we're in the army, and one day--and they had you busy from Monday through Friday, crack of dawn you're up running your butt up a hill and that sort of thing. You're really looking forward to your weekends to sleep in, and I remember there was this movement within my class to ask the instructor to have a boot shining class on Saturday morning at 8:00 am. I was like, you've got to be 00:11:00kidding me. Why in heck--why on God's Green Earth would we wake up on a Saturday morning to learn how to shine a shoe? Every once in a while, those kinds of things would happen and you would think, wow, we're really--I don't know--something is happening here. [laughter] But it was a pretty fun experience. In the end, you find out that it's your colleagues that you're really--your fellow soldiers that you really build a bond with, and it's all of you going through these kind of silly things, and maybe they make these things silly on purpose so that you bond, but you definitely do bond, so it was pretty fun. All in all.

Q: Then is it San Antonio to Michigan to Germany?

CHOI: No, so I went--I finished my residency in Michigan, then went to OBC 00:12:00[officer basic course] in San Antonio and then to Germany.

Q: Right, okay. What was Germany like?

CHOI: It was interesting. It was my first time living outside the United States, and it was my first time in Europe, actually, but it was a really great place to live. One of the hardest parts though is passing the German driver's test. It's kind of hard. It's different than in the United States, but also, your command wants you to pass this test as soon as possible because until you do, they have to drive you around. One of the first things all soldiers arriving to Germany do within one or two days of arriving in Germany is taking this German driver's test. They send you all the materials beforehand. They're like, you need to study this. I remember I took it, but I had just arrived in-country and I was 00:13:00completely jetlagged, and so I went to the testing facility and I tested. It was a written exam. They have questions like, you're at a four-way intersection and to your right there's a donkey-driven cart. [laughter] Who goes first? And it's like, oh my God, I don't know. Then they're like, the person on the right always has the right of way. But if you keep going, everyone is on someone's right. I just didn't get it. I was very jetlagged and it was so confusing and I couldn't figure out whether the donkey-pulled cart goes forward or if the car is before. Anyway, I was very confused, and I fell asleep during the exam. I just went to bed. I woke up, I don't know how many hours later, and I was the only student left in the room and I just turned in my exam and I failed. Which was the first 00:14:00thing I had failed in a very long time. It was kind of upsetting. My command was not that happy. Then I had to take it again and I barely passed. I think I just got enough questions right to pass. But that's probably the hardest thing about moving to Germany. [laughs]

Q: What did you do when you were finally in that situation where the donkey and the cart were on your right?

CHOI: I was like, I don't know. I don't know why I'm somewhere where there's a donkey. [laughter] It's weird. But that being said, there are a lot of rural areas in Germany, so you can get to a donkey-pulled cart, it turns out, pretty--it's not an infrequent occurrence. But yeah, I still don't know the answer to that question. [laughter]

Q: How long were you in Germany?

CHOI: I was there for four years.

Q: Four years, until what year would that have been?

CHOI: From 2003 to 2007. Wait--is that right? Yeah, 2007.

Q: Anything else you remember about your time there? What you were doing?

CHOI: I was an ER doctor assigned to the 212th MASH, mobile army surgical hospital, and so we deployed a lot. The people in Germany are the first-line deployers to Iraq and Afghanistan or to anything else, because we're already over there. We deployed a fair amount, and it was kind of cool because I had seen the show MASH when I was a kid and I was actually in a MASH. Then it turns out we were in the last MASH. They started converting all the MASHs into CSHs, which is combat area support hospitals. They're bigger and they're not mobile. They started converting all the MASHs into CSHs, and so at one point we were in 00:16:00the last MASH standing. That was kind of fun.

Q: Were you in both Iraq and Afghanistan at various points?

CHOI: No, the unit had just come back from Iraq when I joined them. Our deployments were to a lot of medical exercises, and then we deployed to the earthquake in Pakistan in 2005, I think it was. Yeah. That was really busy, but that's where, actually, we gave--at the end of that assignment, we actually gave the military hospital to the Pakistani army, and then that was it. No more MASHs.

Q: Any incidents you remember from that time? Pakistan?

CHOI: Yeah, it was--that's where I actually realized that public health was a 00:17:00good thing. When I was in med school, I thought public health was stupid and there was no reason for it. When we were in Pakistan, we're going to an earthquake, right? We packed all our trauma stuff. We brought the orthopedic surgeons. We brought the general surgeons. Collapses and crush injuries and fractures and all of that. But when we got there, what we ended up seeing was diphtheria and tetanus and measles, and none of us were prepared for that. We were not prepared to deploy to a country that does not have a public health infrastructure and an immunization program. We were there for trauma. At the time, actually, it was really interesting--there were a lot of Pakistani physicians in America that the US government allowed to come and work in the 00:18:00MASH hospital with us. Some of them were pediatricians, and thank God they came, because they really taught us about measles and diphtheria and tetanus, because these are not things that we normally see in the United States. They came, and we worked with them, and we learned a lot from them, and that's when I realized, oh, this public health stuff. They may be on to something. [laughs] Actually, that deployment is probably the reason why I got into public health.

Q: What happens after that?

CHOI: After the army, I moved back to Chicago and I worked in a community hospital on the South Side of Chicago for about two years, which was a really interesting experience. We were not a level one or level two trauma center, but the hospital had been in the neighborhood for a very long time. So people in the neighborhood really felt like, that's my hospital. They would get shot 00:19:00somewhere, and then they would have their friends drive them past all the level one and level two trauma centers and then come to our ER [emergency room]. Then I would ask them, "Why did you pass these level one and level two hospitals and have your friend drive you here?" And they would say, "Because this is my hospital." It's kind of a cool place to work. It was definitely a really good place to learn in terms of there's a lot of trauma, a lot of gunshot wounds, that sort of thing. It was a good place to sharpen your skills.

Q: Were you able to ever think about gun violence at a public health standpoint?

CHOI: It did--yeah, it is an interesting thing. When I was in residency also, one of the hospitals we trained at in Michigan is in Flint, Michigan--it's 00:20:00Hurley Hospital--and Flint, at the time, was consistently one of the top ten most dangerous cities in America with the highest murder rate and that sort of thing. We saw a lot of gun violence in Flint. After a while, you do think to yourself, this is kind of futile. We had one time where there was a man and a woman in a car and some people came up and shot them. The man who was in the driver's seat could no longer drive. The woman who was in the backseat jumps into the driver's seat, pushes the man over, drives to the hospital, the front door of the ER, basically, and everyone falls out, shot. They bring both of them in at the same time. The woman survived, the man dies. And then the doctors go tell the man's husband that he's dead and the family is like, really, really angry, and they're like, "We're going to get these guys." And then, I don't 00:21:00know, two hours later, two more people come in shot. Again, they're sitting in a car. It must have been a machine gun or some sort of semi-automatic weapon because one person, he was clearly dead. I stopped counting after I counted forty bullet holes in his body. The second person survived. You can kind of see--because we were the trauma center--these gunshot wounds don't go anywhere else. When this family says, "I'm going to go get this guy," you see the guy that they got. But it was also the same thing in Chicago. This cycle of violence and that sort of thing.

There was this one time where there was a guy--his mother was actually a security officer in the emergency room in a different hospital, and her son was shot. I don't know why she decided not to call an ambulance, but she decided not 00:22:00to call the ambulance, but then called 9-1-1 to tell them to call us at the hospital to tell us that she's driving her son, who has been shot, to the hospital. The mother arrives with this very young guy, and he's been shot twice, once in the chest and once in the arm. At this point it's like ten o'clock at night. I'm the only ER doc [doctor] in the hospital. This normally is treated by a trauma team of multiple physicians and nurses. We're not a trauma center, so we don't have that. It's just me and a lot of really great nurses. We do this whole--at first he's talking, and I'm trying to transfer him to a trauma center, and then he starts to crash. We do like a full-court press. We put a tube down 00:23:00his throat, we put a tube in his chest, hook him up to these rapid blood transfuser--transfusing blood like crazy. We were able to save him, but the problem was at this point that he needed surgery. We're not a trauma center, and so we need to transfer him. At that point he was stable, but normally you would like to just have the surgeon come in and take care of it and not put him on an ambulance and send him somewhere else. The surgeon's like, "No, no, no, I can go in there and take care of this. This is not a problem." But the anesthesia team was like, "We're not doing it because this is a trauma and we're not supposed to do this," and so that forced our hand and we had to transfer him. But because he had been so ill, the transfer team which came with a nurse was uncomfortable 00:24:00transporting him. So I got in the ambulance with him, and we drove to the trauma center, and we dropped him off, and he ended up surviving. It was kind of cool because later on--I don't know--maybe like two weeks later, I was working the night shift and they're like, "You have a visitor." I was like, that's impossible. I don't have a visitor at midnight. And it was the guy. He had completely survived, and he had come to give me flowers and to thank me. I remember thinking to myself--I said to him, "You are very, very lucky. There was another person at that hospital we transferred you to, he also was shot, and he died." And I said--I was pretty frank with him, I was like--I basically told him, "You have to stop that shit." I never asked him what he was doing, but I 00:25:00just said, "You're going to stop this shit. Because you're going to die. The next time, you're going to die." I don't know whatever happened to him. Hopefully he heeded my advice. I don't know.

Q: It's amazing, you went from that time when you were I guess in high school and really freaked out about who might come through the door, to see some of the grizzliest, craziest, scariest stuff that you can see.

CHOI: Yeah. Yeah. I guess I had good training. [laughter]

Q: How do you adjust to that?

CHOI: I don't know. I think on some level for sure, when you work in the ER, you do have to step back a little bit. Once you're too emotionally invested, it's hard for you to make a decision. I can make a decision on how to save this guy 00:26:00from a gunshot wound, but once, I tried to prescribe my father penicillin for something that was like nothing. I agonized about this decision for like three hours. I was like, he's not allergic to penicillin, but what if he goes into anaphylactic shock? Then what will I do? Maybe I should order him other medicines to treat the anaphylactic shock. Then three hours go by and my dad still doesn't have a prescription for penicillin. In order to be a good doctor, you do have to be able to step back a little bit because otherwise it gets a little hard.

Q: What happens after 2007?

CHOI: At this point, I missed public health. I missed deploying with the army. So I thought, I will go into public health. It turns out there is something called an international emergency medicine fellowship, and I found one at 00:27:00Columbia [University]. It was a two-year program, and with it, you get an MPH [master of public health degree]. I was like, perfect. This is what I want to do. I applied, and I was lucky enough to get in. So I moved to New York City.

Q: How was the program?

CHOI: It was great. It was great. It was a really good experience. Going to school and getting an MPH and learning from all those public health practitioners and all the professors and everything and learning from my classmates was really a great experience. Yeah, a really great experience.

Q: Did you study something in particular?

CHOI: We didn't really have a choice. It was forced migration. We did a lot of things with refugees and that sort of thing.

Q: Am I right in thinking that at that program, you met some people who would later come back around for your Ebola experience?

CHOI: It was in that experience that I found out about the EIS [Epidemic 00:28:00Intelligence Service] program. We have to do a practicum for our MPH, and so I ended up doing a childhood mortality survey in Sierra Leone. For that survey, I worked with the International Rescue Committee, IRC, and they actually worked with some people from the refugee branch here at CDC. When I was in Sierra Leone helping manage the study, the CDC team came out, and I spent like a month with them. It was a really great experience. Learned a lot. Met someone named Colleen [M.] Hardy who works in the refugee branch--she's fantastic. Learned a lot from her. She talked to me that there's something called EIS, and that I should consider it, and that sort of thing. It stuck with me. Once public health school was over, I kind of wanted to still practice medicine, but also do international 00:29:00work. I tried doing that, and I realized it's very hard to do. I basically ended up having two full-time jobs. I worked a full-time shift in the ER, and then I would then fly intermittently to, at the time, South Sudan to set up another survey for the international Rescue Committee. I realized it's very hard to do both, on a full-time basis anyways. I remembered Colleen talking about EIS, and so I went ahead and applied and then I was lucky enough to get in.

Q: What class year were you?

CHOI: Two thousand twelve.

Q: Twenty twelve. Got it. So you did it from 2012 to 2014.

CHOI: Exactly.

Q: Can you tell me about some of the assignments that you had for EIS?

CHOI: I was actually in the Minnesota health department, so I took a state position. One of the other people in public health school that I met was Les 00:30:00[Leslie F.] Roberts, and Les Roberts was an EIS officer, and actually I think he's the first winner of the [Paul C.] Schnitker [International Health] Award. Anyway, I had totally thought when I joined CDC that I would work with Colleen and her branch or do something global, international. But I realized I really wanted something just a little bit more general. It might just be because that's who I am. Being an ER doc, little bit of everything. He recommended that I look into Minnesota because even when he was an EIS officer they had a good training slot, and so I went ahead and went to Minnesota, and it was a really good experience. They're very well known for their abilities to solve foodborne outbreaks. We had a really cool Listeria outbreak that was associated with cheese. I had my "a-ha moment" when I figured out which cheese it was, which was pretty cool. That's a high that can't be replicated. [laughter] That was cool stuff.

I worked on a project on swine flu within the Hmong and Somali community, and so I did a lot of work with the Hmong community, which is really kind of cool. They have a very large Hmong community in Minnesota. It was very cool, learning about their culture and their beliefs and their thoughts about medicine and Western medicine and that sort of thing. A really, really good two years.

Q: Is it right that you actually had a Lassa fever case while you were in Minnesota?

CHOI: Yeah, it was a couple months before I graduated. His Lassa diagnosis was confirmed on April Fool's [Day]--it was April 1st. We found out that there was a man that had been visiting family in Liberia who came back and was quite ill, 00:32:00and he subsequently was diagnosed with Lassa. Working on that case, I got to meet--or, not meet--got to know some of the Viral Special Pathogens [Branch] people by phone. At the time it was Stuart [T.] Nichol and Barbara Knust there on the calls with us a lot. I remember talking to them on the phone. By the end of that month, right around then, is when the Ebola outbreak in West Africa was starting, and they needed someone to go to West Africa in May, I think it was. I applied, and they said okay. So I went to Guinea.

Q: Had you been in West Africa before? You'd been in Sierra--let's see.

CHOI: Yeah, I had been in Sierra Leone--

Q: Sierra Leone, that's right.

CHOI: --but never Guinea.

Q: Never Guinea before. Do you speak French?

CHOI: I took French in high school, and I continued to take lessons throughout college and residency and even after residency, but what I would say is that I'm an intermediate French speaker. Not fluent, but not basic, but intermediate.

Q: Got it. You got some skills.

CHOI: A little skills. Turns out not enough, but yeah. When they selected me to go, I said, "Just to be very honest with you, I only speak intermediate French. I'm not fluent, but I know more than basic, but I'm intermediate." And they said, "Yes, yes, yes, no problem." But when I arrived in Guinea, I realized that you're either fluent or you're not. It was actually kind of funny because I was in Guinea, it was the end of my first week, and during the day time I would be 00:34:00so tired. I'm thinking to myself, it's been a week, it can't be jetlag. And then I realize that my fatigue goes away when people stop talking to me. When I would go back to my hotel at the end of the day and no one's talking to me, I would be wide awake. Then I realized it's not jetlag, it's confusion. I'm trying so hard to understand what these people are saying to me, I make myself sleepy. It was kind of hard. I would say I probably picked up on seventy percent of what people were saying, but it wasn't that great because they wanted me to be a contact tracer.

Basically, what you do is you go to a village where there is an Ebola case, and then you interview all these--and then that person in the hospital then tells 00:35:00the health care professionals, "These are all the people I had contact with while I was sick." Those names would then be passed out to the epidemiologist, and then we would have a list of names, and we would go to the village and find these people and talk to them about their exposures or whatever. The problem is that if you only understand seventy percent of what people are saying and you don't have a very good grasp of tenses, it's kind of a problem. It was very obvious to me that I was not suited for this job because I just didn't know French that well, which was really stressful because I came all the way out there, I'm trying to be helpful, and I feel like I'm more of a drag on the system than an actual benefit. I was talking about this with a friend of mine who is another EIS colleague that was with me, and he was trying to help me out. He was like, "Maybe we can find someone to interpret for you," but that didn't 00:36:00really pan out. But he kept me in mind, and one day he said to me, "WHO [World Health Organization] has decided that they're going to start opening health clinics in villages that have a lot of Ebola cases in which there is no nearby health facility," because the fear was that these people or their contacts would eventually develop symptoms. Then because there's no healthcare facility nearby, they would get in taxis or motorcycles or whatever and leave the area and subsequently infect multiple people and spread the disease to other villages. And so the WHO decided they were going to open up clinics. Basically what they would do is they would go to these villages and they would find an abandoned building. They would find physicians and support staff, and they would staff it, they would drop off a bunch of supplies, and a clinic was born. My friend said, 00:37:00"You're a doctor, so you are just going to go to one of these clinics and start seeing patients." I was like, huh, okay. I thought I was here to do public health, but okay, that's fine. I can do this.

The WHO had dropped off all these supplies. The next day I go to the clinic, and the clinic is open. I meet the chef de poste, who is like the doctor, and he ushers me into this very, very, tiny, tiny room. In this room, there's this desk, there's a patient bed, and there's a patient, me, and the doctor, and we could barely fit in this room. Then the door closes, and then the patient would explain all her symptoms and whatever, and the doctor would muse out loud about the differential diagnosis and would ask me basically, "Do you concur?" One of 00:38:00the first patients we had was a woman who was complaining of a fever and muscle pain and whatever, and the doctor was like, "I think it's malaria." I'm thinking to myself, or Ebola. This clinic was basically set up to find Ebola cases. This woman could have Ebola, and we're sitting in a teeny tiny room, he's touching the patient, he's using a stethoscope, he's putting that stethoscope back on the table that has all his paperwork and his pen that he's picking up and down, and I'm thinking to myself, this is very bad. All the personal protective equipment and supplies like the chlorine buckets and all that are sitting in a corner of this clinic and gathering dust. It was really hard for me to concentrate on his 00:39:00question of, do you concur with this diagnosis, because I was thinking to myself, this is so unsafe. We saw another patient and exact same thing. Again, he said more symptoms that could be Ebola. Finally, I just stopped and I said--I was there by myself. The WHO car had dropped me off in the morning and then would pick me up at night. I finally just stopped him and I said, "Listen, I'm not going to do this anymore. What I'm going to do is I'm going to help your clinic prepare for Ebola."

That became my job. No one told me, but that's what had to be done because if we continued to do this, all these people were going to get infected. All these workers that I saw every single day were going to get infected. So we started developing triage because they didn't triage anybody. All the patients just walk 00:40:00in. Basically, we set up a triage system. We had a bench where all the patients would sit. We set up a chair where one patient would be directed to come, sit at the chair. He would then talk to the triage officer, but the triage officer is not a medical person, and all the forms that are looking for Ebola symptoms use medical terminology like "asthenia" and "myalgia"--this guy doesn't know what these words mean. One of the first things we did was we went through the list and I explained what each symptom was in my terrible, terrible French, with a lot of pantomime; he would then write down, in his own words, what these words meant to him, so that when he would ask these people these questions, he actually knew what he was asking about. If this person screened negative, meaning they didn't report any symptoms or concern for Ebola, they would be invited to come in, and then the doctor would see them. If, though, the patient screened positive, there was a second area of this clinic that they were using 00:41:00basically as a break room, they would eat lunch in there. I said, "This is no longer a break room, this is the isolation area." If someone screened positive, the patient could not come inside the clinic, but instead go into this isolation area. The thing is it's not the triage person who is making this decision by himself. Once he fills out the form, he runs it by the doctor. The doctor has looked at this form and said, "Yes, I agree with you, I think this person is concerning for Ebola," and then they would be escorted into this isolation area.

Then the issue was that MSF [Medecins Sans Frontieres] at the time wanted everyone to have a temperature taken. Even though your temperature can fluctuate during the course of your Ebola virus infection--just because you're afebrile on temperature at this moment doesn't mean that you don't have Ebola--they still wanted a temperature taken. But at this point in the epidemic, no one had those 00:42:00thermal scanners. The only thing we had was a mercury thermometer. The question was how to take a temperature on a suspected Ebola patient without getting infected. This is where we got a lot of help from MSF because this town was an Ebola hotspot. MSF would always be driving around.

Q: Can we--just for a second--which town is this?

CHOI: Katkama.

Q: Katkama. And you're based nearby?

CHOI: I'm in Gueckedou.

Q: You're in Gueckedou.

CHOI: Yeah.

Q: Okay. And then every day the WHO bus takes you to Katkama.

CHOI: Yeah. The car.

Q: Right. The car, sorry.

CHOI: Basically, they would go off to do contract tracing in another town, so whoever was closest who had run by my village, I would get in their car.

Q: Would get in the car. Okay.

CHOI: Yeah. I would just hop in their car, and they would drop me off, and then they would go.

Q: Right, and this is after how long in Conakry?

CHOI: It was probably like two weeks. I only spent like two or three days in 00:43:00Conakry, then I went to Gueckedou. I flailed around in Gueckedou for about a week until this thing happened.

Q: Okay, cool. I'm sorry, I interrupted. You were talking about MSF and--

CHOI: Oh yeah, yeah. So MSF--I would talk to MSF and other colleagues about how I am at this clinic, and this is a problem I'm having, and what do you think, and pick their brain. MSF is like, no, there's a way to take temperatures. Basically, they taught us how to take axillary temperatures on patients. Basically, what you would have them do is you have the patient turn around so their back is towards you, and then you would ask them to raise one arm. Then, from behind, you would approach and stick the thermometer underneath their armpit, and then you asked them to put their arm down. Then when the thing beeped or whatever, you would go check it. The whole reason for this is you're never facing the patient. So if the person were to start vomiting or coughing or 00:44:00something like that, you would not be exposed to their bodily fluids. It was pretty brilliant. I'm like, fantastic, can you come and teach us how to do this? So they came to the clinic and they taught me and my staff all how to do this, and that's what we did.

The other thing was, I don't know how to make chlorine solution. I don't know anything about chlorine solution. MSF does, though. Again, we asked them, "Hey, can you stop by and give us a lesson on chlorine solution?" They taught us how to make chlorine solution. They told us how to properly store it and that sort of thing, how often we had to change it. Again, they taught me and my staff, and then we made little posters on the wall so we would remember how to make the chlorine solutions. Just kind of slowly like that--just grabbing people that I knew had expertise in different things, and bringing them, and having them give us lessons--we built up our capacity.

One of the things that I knew how to do but that I realized was an issue was 00:45:00glove use. We had gloves, but you have to take them off properly or else you'll basically contaminate yourself. I would twice a day have lessons. We would practice where everyone would put on gloves and everyone would have to take them off. Putting on the gloves is also--finding the right size. You'd have all the different sizes and I'm like, put on the one that you think fits you, and then we would check. Oh yeah, this one's a little bit too small, you should go up a size. Oh, this one's too big, you should go down a size. That sort of thing. Once we figured that out, we went to the point of practicing how to take them off. The thing that I had always told them is as soon as you put on the gloves, even if you touch nothing, you must assume that your gloves are contaminated. So you have to take them off without contaminating yourself. But no matter how many 00:46:00times I said that, every time they would take them off, they would still touch their bare skin in the process of taking off these gloves. I realized it's because they don't understand this concept of your gloves are contaminated.

I thought, in America, what we would do is we would get some black light and Glo Germ and we would do an experiment with Glo Germ. You put it on your gloves. You put Glo Germ all over, and then you would take it off, and then you would shine a black light and if your hands fluoresce, that means you contaminated yourself. But we don't have this in West Africa. I thought about trying to see if I can order it, but it's going to take too long and that sort of thing. I need to find something else. Then I realized, I'll just use mud. What I did was I took them outside and I poured my bottle of water on the ground. Which I did feel a little guilty about because they must have thought that was pretty wasteful, but anyway. I made mud, and then I had everyone dip their gloves and just smear mud 00:47:00all over their gloves. Then we would get into a circle and I would watch each single person take it off. And then when I told them, take the gloves off without getting any mud on your skin, then they understood what I was trying to say. They're like, oh. Either that or maybe it's my bad French, I can't tell, but either way there was an epiphany, one way or another. They took off all the gloves and it worked out really well. We practiced that twice a day.

I did this for a little bit. I brought in my friends--my WHO colleagues, my CDC colleagues, to say hey, what do you think? Are there some things about this clinic that you think I should do differently? What do you think about this protocol that we implemented? That sort of thing. They were aware of what I was doing, and they started telling me about other clinics that WHO had set up. They 00:48:00were having issues, they thought. So they were like, "Hey, if you're done with Katkama, can you please come out to other villages?" Honestly, I didn't want to leave because I was having a pretty good time in Katkama. [laughs] Every time I would come, all the little boys in town would come over and hang out and we would play and that sort of thing. But I was there to work. So I started going to the other village and doing similar assessments there.

The thing is these villages--they were not all the same. Some of these clinics were way better off, where they knew how to make chlorine, everything was set up, but their issue was they didn't have an isolation area. They just had a one-room hut, and they didn't have an isolation area. For that place, it was actually interesting. There was a half-built cooking hut, and so the walls were up, but there was no roof. It was a small little mud hut that was supposed to be 00:49:00used for cooking but it was never finished. I thought, this is perfect. This is your isolation area, because it's right next door to the clinic. All we did was ask the village chief to bring in their carpenter, and we paid him to put on a roof. He put on a roof, he finished up the walls, and we had an isolation area. Another place, it was the same thing. They didn't have an isolation area, but I realized that in that building all you needed was one door, because basically it was a two-room house, but it didn't have a door. There was a place where a door would go, but there was just no door there. So I said, this is perfect. You have an isolation area, you just need a door. Again, the same thing, we found a carpenter and we ordered a door. Then the problem was solved.

Q: I have a question, backing up, about how people in Katkama or after responded 00:50:00to these directions for how to change and how to become--how to prevent infection. Because these are fundamental changes to how they do things.

CHOI: They were very, very receptive. I think at this point, everyone knew that healthcare workers were getting infected and dying. A lot of them were dying and getting infected. So they were very happy to hear anything that was going to help keep them safe. A lot of this stuff--I'm not from the town, I don't know all these things--so basically, when there'd be a problem, I'd be like, how do you think we should solve this? And a lot of the times, they are the ones who solved the problems. Even with the clinic when I was like, we need to rearrange this and make it neater and move some of these things out of the way so they 00:51:00don't get contaminated, they're the ones that came up with the idea of shelves and how many and where and what they would put on the shelves and that sort of thing. I just asked a question and they knew the answer.

Overall, they were very happy to learn all these things, and there was no resistance whatsoever. I think it's because we're all trying to keep each other safe. That's what I kept saying the whole time I was in Katkama. One of the things we did is we had this little triage area, but in order for people not to just barge into the clinic without being triaged, I put a rope across the door. The triage officer was responsible for the rope. Basically, what I said was, "Everyone in this clinic is your family, and you need to protect your family. No one comes in past these ropes unless you let them in because this is your 00:52:00family." I think we all kind of understood that we all were trying to keep each other safe, and so there were no problems.

Q: What happens then, after going to that other clinic and checking that out?

CHOI: At the end of it, my time was up. So I came back--

Q: When would that have been?

CHOI: That was like the end of May.

Q: End of May? Got it.

CHOI: I came back to Minnesota, and I got a job with the Division of Healthcare Quality Promotion at CDC Atlanta. I packed up my stuff and moved to Atlanta, and I was in DHQP. I was on the job for like--at that point the EOC [Emergency Operations Center] had been activated. It was probably a pretty low level at the time, like maybe a level one or something. But I was in DHQP, I was in my office 00:53:00for about three days just reading stuff that they were giving me, and they said, "The EOC's been activated. We need to have a representative at the table from DHQP for the EOC response, and since you just came back from Guinea, you should go." So I said, "Fine." I showed up to the EOC in this little conference room, and they're like, this is where you sit. There's a chair there, and there's the sign, and it said "healthcare worker safety." I was like, oh, I guess that's what DHQP does. Healthcare worker safety, because that's the sign that I'm in front of. The outbreak had ramped up considerably, and they were in the process of trying to send out fifty deployers in thirty days, which at the time was unheard of.

Our job became trying to deploy all these people, but keeping them safe in the 00:54:00field. Part of that was we had to draft a one-pager about pre-deployment activities, deployment activities, and post-deployment activities. What would you do if someone came back and was sick? What would you do if someone was over there and got sick? How would you get them back? How are you going to prepare these people to go? That led me into a working group that developed pre-deployment training slides. I worked with VSPB [Viral Special Pathogens Branch] on that, and we would give lectures to all the deployers about Ebola. I would talk about my experiences, and we would talk about things not to do. A lot of that was learned based on stuff I almost did or did. [laughs]

Q: Do you have an example?

CHOI: Right now, the rule is you're not allowed to go inside an ETU [Ebola treatment unit]. When I was in Guinea, in Gueckedou, there was an MSF hospital there, and there's these two French Canadian ICU [intensive care unit] doctors that were there. I don't know if it's true or not, but apparently, what they were telling me was that the MSF hospital prior to their arrival was basically a staff with very young, junior physicians who were not very good at starting IVs [intravenous lines] and that sort of thing. When they went in there, they said, no one was getting IVs and that sort of thing. So they went in and started all these IVs. But their time was short. They were only there for about a month, and they were about to leave. They knew that I was an ER doc, and so they said, "We want you--" They were leaving the next day, so basically what they said was, "Tomorrow, we would like you to go to the MSF hospital and find this guy named," 00:56:00I can't remember, like William. They're like, "William is good because he speaks French and he speaks English. We know about your bad French, so you'll be okay. Then I want you to go inside the ETU with William and I want you to start the IVs on all the patients inside the ETU." I was like, that does not seem like the best idea because I've never been inside this ETU, I've never put on all that PPE [personal protective equipment] before. At the time, the head of the Ebola response was also in Gueckedou, and these guys had told their plan to the head. The head guy is trying to get me to do it. He's trying to corner me into conversations. I don't know what to do, and so I called my supervisor at the time--very nice man--and I said, "Listen, these guys want me to do this thing," 00:57:00and I'm like, "What do you think?" He's like, "I don't know, what do you think?" and I'm like, "It doesn't sound like a good idea." I think if I had gone in before and been used to it, then I would do it. But he was like, "I support whatever you want to do." But it wasn't all that clear to me. I ended up not doing that, but later on, there was an opportunity to go inside the ETU. A friend of mine had to fix an i-STAT machine inside the ETU, and I knew something about i-STAT machines because we used them in the army, and so I said, "I'll go in there and help you."

I was able to go in and do that, but I've known people who have been pressured very strongly by very, very high-ranking officials to do things that are dangerous--frankly dangerous. One person I knew who had never been to an Ebola 00:58:00outbreak, never been inside an ETU, never put on all the PPE, was basically told by a very high-ranking official that the next day he was going to travel to this town where there was this hospital with a couple of Ebola patients and he was going to turn that ward into an ETU. He was going to treat the patients, and then he was going to train everyone on how to work in an ETU, even though he had never been to an ETU or an Ebola outbreak before. He almost agreed to do it because they were pressuring him so bad, and he's like, I came all the way over here, I want to help out, I don't want to be a waste of space. He almost felt obliged to do it, and I was like, don't do it. Do not do it.

I drew upon these kinds of experiences, and we made a list of things that people are not allowed to do. Basically, my argument was back in the day, the EIS officers and VSPB--I'm sure they did a whole bunch of stuff that we don't know, 00:59:00right? But the thing is, you're going with--it's a small number of people, and you're going with the SMEs [subject matter experts] on Ebola. This is completely different. This is fifty people who have never been to an Ebola breakout before, just thrown out of the country to work on an Ebola outbreak without that close oversight. It's a completely different ball game. I said, we need to have rules. Because they may not adhere to the rules, but you need to at least make them and to know that these are the rules, and if they don't feel comfortable about doing something, they can say, I'm not allowed to do it. They don't have to take the flak for it. They can just blame CDC. We kind of made up these rules, and then--it's kind of funny because like a year later, people came back to me and they're like, CDC said we're not allowed to do this. And I was like, that was a random rule that I just made up. [laughter] I think it was helpful because there 01:00:00were situations where--when you're out in the field and you want to be helpful, sometimes you may sacrifice your own safety, and we just could not have that happen.

It was good experience. It was kind of fun talking to people as they deploy and trying to give them a little bit of a taste of what it will be like so they know what to expect.

Q: What kind of feedback did you receive from them? During, and maybe even when they came back?

CHOI: I got some feedback. Mostly, they were happy that we made it okay for them to question things. Because that was one of the things that we had said was that if you feel uncomfortable doing something, that you need to talk about it. That 01:01:00you shouldn't feel forced to do something that you're not comfortable doing. And that they always had someone they could call. If you're being forced--maybe it's a miscommunication, maybe it's something that's whatever--just call us in the EOC. Just call us, and we can help facilitate this conversation. I know that people have expressed some happiness that someone said that to them. Because no one wants to be that girl or that guy that's the chicken. You don't want to be that person. But we always tried to stress with them that it's safety first, and if they can't be safe, then it shouldn't be done.

Q: Sorry, this is not chronology at all, but I have another question going back. When you were talking about the MSF ETU and what you were asked to do, it 01:02:00brought it up to me. When you were creating, innovating those ways to change the infection control practices, the processes, in Katkama and subsequent clinics, did you have a model or was it really just logically, this is what has to happen?

CHOI: It's a little bit of both. Before we went to the outbreak, VSPB had given us a stick [flash drive] with a bunch of articles, and one of them is the [Esther] Sterk manual. It's written by someone from MSF, and it talks about Ebola and how they set up their ETUs. When you go to your first Ebola outbreak, it's just really scary. First of all because it's things you don't even tell your parents. My colleague didn't tell his mother. I didn't tell my parents at all. It's kind of a scary thing, and the only way I realized to get over my fear 01:03:00was to learn something. I devoured these articles that they gave me on the stick. I read them multiple times. The Sterk manual was something that I read a lot. A lot of the principles came pretty much from that manual, but the other stuff came from being an ER doc. Triage is the number one thing in ER. We always triage. The idea of triaging symptoms is natural for me because that's what we do all the time. We triage symptoms. But I think it's a combination of both. Probably just my time in the ER and also just being very, very scared and reading a lot of articles.

Q: What I know about the ETUs as set up by MSF is that they have this cycle from clean to dirty and--

CHOI: Yes.

Q:--so I don't know if that was--

CHOI: Yeah. Yeah. For sure. The whole idea of clean and dirty and keeping that separated was a big deal, and then it was really nice because one of the people that I asked to come to the clinic is this woman who worked in the ETU in Gueckedou. On one of the days that she wasn't inside the ETU, she actually came out to Katkama and looked at the flow of everything and was able to give me a lot of really good insights on how to do this. For Katkama and for a lot of these other places, MSF, CDC, WHO, we all just kind of work together.

Q: Can I also ask, who were some of the people you worked most closely with while you were in Guinea?

CHOI: Let's see. I worked with Matt [Mateusz M.] Plucinski. He and I came 01:05:00together. Then there's KP [Kpandja Djawe], he was there. He was the one who got me the WHO clinic gig. Then there was Frederique [A. Jacquerioz]. She was actually--she's with WHO. Interestingly, Frederique is married to Dan [Daniel G.] Bausch, who used to work at CDC in Viral Special Pathogens. But this was her first Ebola outbreak. Frederique and I were together. At the end of the day when we were scared about something, I think Matt talked to other people, because he didn't talk to me that much. It might've been a man thing, I don't know. But Frederique and I, we would have these random crazy fears and we would run them by each other. At dinner I would be like, "Okay Frederique, this is what happened. I was standing here and then this person was standing over there and then the wind changed and this person might be an Ebola patient. What do you 01:06:00think? Do you think that I was exposed?" We would just say really crazy, paranoid things, and then she would laugh at me and tell me I had nothing to worry about and I would laugh at her and tell her the same thing. When neither of us were really convinced, she would then call her husband. Then the next day she's like, "I talked to Dan. Dan said it's fine." But it was really good to have that because you do have these kind of irrational fears, and if you have no one to talk to, it gets kind of hard. Being there together and talking about our crazy fears, we were able to calm each other down. We were like, well, we read this paper and that's not what this paper said. We were able to rationalize and keep each other calm. It was really good.

Q: And then were you working on the pre-deployment briefings with certain individuals?

CHOI: Yeah. I worked with Bobbie [R.] Erickson and then this other guy. Oh gosh, I'm blanking on his name right now. I think he works for OPHPR [Office of Public Health Preparedness and Response], and he did--George, George [A.] Roark. Yeah, George is awesome. He pretty much did the whole--so I did the briefings from maybe August through January or something, but after a while I started getting deployed so I couldn't do them all the time. But George did them pretty much until the end. It's funny because like I told you, we had these rules. I want to be clear about the rules, and one of the slides is called--George calls it the "do not" slides. When I read them, I read them rather forcefully. Like summoning 01:08:00up my army. I would read them, and just to be very clear that you're not allowed to do these things. George is like, "Mary, I love it! I love it when you read your do not slides! You just get all"--because he's army too--"you get all army and tell them do not whatever." Yeah, so George is awesome. He gave almost all of them after a while.

Q: You did the briefings from August until when, did you say?

CHOI: It was a continuous thing because the briefings would be--in the beginning it wasn't scheduled, so we would just do them whenever. After a while, it came on a schedule. I probably did them until, I don't know, November, December.

Q: November, December, okay. I'm pretty sure you also had deployments during 01:09:00those times. Can you tell me about those?

CHOI: After a while, I--let's see--so I was working for DHQP. The other thing was we were developing infection control slides for Guinea, Liberia, and Sierra Leone. Basically, what happened was Sierra Leone told us that the WHO had given them some slides about infection control for health care providers in Sierra Leone, and that they were going to have this training coming up and they were going to use these slides. I said, okay, that's great. Can I look at them? I looked at the slides, and the slides were great, but the problem was that they were really geared for someone who has a very, very high degree. They had a blowup of a wall of the virus, and they had all these little things labeled, and 01:10:00I thought--and then they had this genetic analysis chart up there. There was just no way that most people, even many physicians in the US, would understand what these slides were saying or what was on these slides. I thought to myself, this is not going to be very good, because you're going to do these slides and then no one's going to learn anything.

I told Sierra Leone, I said, "Listen, give me a little bit of time. Let me come up with some slides. I'll follow the template the WHO is using in terms of the topics that they're covering, but let me try to do it another way and then at the end of it, you compare. If you still like the WHO slides, you can use them." I have no power to do anything else. "But look at my slides, and if you like those better, you can use them. But if you don't like them, you don't have to 01:11:00use them at all." We basically came up with a bunch of slides, and one of them was a slide called, "Prepare your clinic for Ebola," and it was completely based on the stuff that I did in Katkama. Because the issue at this point was that the doctors and the healthcare providers in the ETU, although some of them were getting infected, most of the infections were happening in non-ETUs because that's where the people are going, and that's where people are not trained. Because when you're in a regular clinic, you don't know who has Ebola. When you're in an ETU, you know who has Ebola. So it's the clinic that's really the high-risk setting. We developed the slides, they looked at them, and they're like, we like yours better, and I'm like, perfect. They used them, and we then continued to develop and refine them because they were pretty rough in the beginning because they were done so quickly. In the end, Liberia, Sierra Leone and Guinea ended up using these slides and then built upon them because each 01:12:00country was different. They built upon them.

In the process of all this, the stuff in Dallas happened. When the nurses got infected, they sent me and a couple people from NIOSH [National Institute for Occupational Safety and Health] and Pierre Rollin from Viral Special Pathogens, and we went to Dallas for like two weeks or whatever it was. Then right after Dallas, New York happened, so then I went to New York.

Q: Can you tell me about Dallas a little bit? Like what you found there and what you were doing then?

CHOI: It's really one of the most difficult experiences. When we went, the one nurse had gotten infected, and so already the tone was quite challenging. There 01:13:00was a lot of fear, I think, the majority of it fear, and then that warped into anger, mistrust. It always turns out that way. There's always finger pointing, who's fault is what, and that sort of thing. I think it's really fitting, the day I flew into Dallas there was a terrible thunderstorm. It was kind of a foreshadowing of what it was going to be like when I was in Dallas because the entire thing was a thunderstorm. The environment was very, very hard because the nurses were all scared at this point. People were quitting. People weren't showing up to work. It was a very, very challenging experience. Then the hospital staff, some of them were very upset and angry about the whole 01:14:00situation. So there was a lot of tension. Then the media didn't really make anything any better.

But really, what we wanted to do was observe how they did things. Our mission was never to find out--everyone wants to know, what did they do wrong? That's basically the question. The thing is, in anything, any sort of root cause analysis, like when a plane crashes or there's a medical error, it's never that one thing. It's never like, oh, the pilot turned left and he should've turned right, the nurse did this when they should've done that, the doctor did this and whatever. It's about, what are the circumstances that are in place that allowed this thing to happen? When we were in Dallas, our job was never--and we never once tried to figure out, what is that one thing that happened that caused this 01:15:00to occur? Because it's not one thing, it's everything. Really, what we did was when we went there, we observed their practices, and a lot of what they were doing was already right. Other things we just tweaked. I think one of the things we did which was really helpful is that we decided that we were going to be inside the unit with the nurses to serve as a coach. The problem is that when you put on all this PPE, what you put on dictates how you take it off. If you wear something different than me, how I take things off and the order that I do is different than you. The problem is that if we're all used to doing this because we've been practicing for years and years and years, that's fine and I don't really need a coach. But when you've never done this before, you're 01:16:00wearing things you've never worn before, then you really need someone to walk you through it because when you put on all the stuff they wore, it's like thirty-some steps to take it off. Thirty-some steps. There's no way anyone's going to remember that. One of the things we did was once we figured out what they were wearing and we all agreed on how they were going to take it off, Pierre, Eric [J. Esswein] and I would alternate and go inside, and we would be coaches. One of us would be on the outside and we would watch them put everything on. Then they would come inside and they would work, and when their time came to leave, either Eric, Pierre, or I would be inside and we would walk through each step. We would literally read these steps to them, and then we would watch them take it off. Because no one can memorize thirty-some steps, 01:17:00especially at the end of the shift when you're tired and hungry and you have to pee. It really did help.

I remember at one point, there was a nurse who was coming out, and she was taking everything off just fine, but it's just that every time she would wash her hands with the sanitizing wipe, she would miss the back of her left hand. It's something that happens normally. When people wash their hands, they always have these charts of all these little places that people miss when people wash their hands. And it's true. It happens. But with Ebola, obviously, it's a big deal. The point of these sanitizing steps is to clean your gloves of any sort of pathogen so that you can take off the next thing safely. Every time she washed with the sanitizing wipes, she always missed the back of her left hand. I would have to actually stop her and say, "You missed the back of your left hand," and she would be like, "No I didn't." And I would say, "Yes you did. Look. It's not wet." So, really being there and coaching them and catching these things. Then 01:18:00what will happen is, gloves will go flying. Things that are not supposed to come off will just start flying off. It just happens. To have someone there who is kind of calm and like, okay, let's stop and think about this. What are we going to do? I think that was really, really helpful. We did that pretty much for the whole time we were there. Then once all the nurses were evacuated to other hospitals, we stayed and trained some two hundred hospital staff on how to put on and take off and how to be coaches and that sort of thing. Then we gave advice to their laboratory folks about what PPE to wear, how to process specimens. Then we did the same thing in the ER. How to evaluate patients, what 01:19:00to wear, that sort of thing. We did that for about two weeks or so.

Q: Cool. And then from there to Dallas pretty quickly? Let's see--

CHOI: Yeah, then to New York.

Q: I'm sorry, to New York. Excuse me.

CHOI: The one thing I would say about [Dallas], and I think this has been really missed by the public and the media, is that for sure, without a doubt, those nurses were absolute heroes. They took care of the patient with Ebola. Then one of their own got infected. Despite that--sure, some of them quit, some of them didn't show up to work. But despite that, their colleagues did come to work and it was really, really scary for them because the nurses that got infected, they 01:20:00were very good nurses, and their friends did the same things they do. Their procedures are the same. So their friends were nervous that they were going to catch Ebola. I remember at one point, I was inside, and they're like, "A person's coming in." I said, "Fine." We wear these PAPRs [powered, air-purifying respirators] and I can see their faces. She comes in to the unit and I turn around to say hello, and I realize that she had been crying. What it was is that she was scared. She was really scared because she worked alongside these nurses, and she was really scared that she was going to get sick with Ebola. And despite that--she cried, and then she put on her PPE and came into the unit and took care of her friends. It's such a heroic thing. Even the nurses that got infected, they voluntarily took care of somebody with Ebola. It's not like 01:21:00something they were prepared for. They didn't have any advance notice. They didn't have time to train, and this and that, and get everything ready. That really takes a lot of guts. I think somewhere that got lost.

Q: Were you doing the same kinds of things in New York that you were in Dallas?

CHOI: New York was much, much more prepared, honestly. They had been training for a while, and actually, right before the patient was admitted in New York, DHQP had a team out there and they were inspecting the hospital. They were very prepared. When we got there, certainly they had some questions and this and that, but it wasn't nearly as intensive work for us as it was in Dallas.

Q: Aside from the deployments in Dallas and New York, through your time on the response, did you have other deployments?

CHOI: Yeah. They sent me over Thanksgiving to Liberia for the first time. There was a Monrovia Medical Unit--it was the hospital that the Public Health Service had set up for Ebola patients. They wanted someone to do an infection control assessment. Since I had gone to Dallas and New York--they wanted Pierre to go, actually, but he went to Mali, so Pierre said, "Send Mary." I went and did an inspection over there. Spent a couple of weeks there.

Then at one point, I was in West Virginia because there was an incident where there was one person with an NGO [nongovernmental organization] that contracted 01:23:00Ebola, but he was living in a group setting with a bunch of people, like ten other people. There were basically ten contacts. They're all Americans. The concern became, where would we put and watch ten contacts if we evacuated them? Ten American contacts? If we evacuate them back to America, where would we put them? We could do one or two contacts here or there, but if you had ten or twenty, where would you put them? One of the ideas was to put them in a facility in West Virginia. So I went to West Virginia to check out the facility. It was interesting.

Q: What did you see?

CHOI: It was a healthcare facility, it was a government healthcare facility. They had a couple of options. One of them was housing. They actually had 01:24:00housing. The other option was these trailers, these FEMA [Federal Emergency Management Agency] trailers that were left over from something. We were looking at these kinds of things and we're like, people probably won't be all that happy being in this trailer. But it was kind of an interesting experience to scope it out.

Q: Did you end up evaluating it, like yes this is an okay place, or no it's not?

CHOI: Right, exactly. We ended up writing a report.

Q: Can you tell me what the report said, or no?

CHOI: [laughs] I'm not sure.

Q: That's okay. We'll move on. Other deployments after that?

CHOI: After that it was--I came back and I ended up switching groups, so I stopped working for DHQP and I decided to work on Ebola full-time. I moved into Pierre's group, and three days after joining that group, they sent me to Liberia 01:25:00to start a semen testing program. I've been working on that since July of 2015, and continue to work on that until now. I've been back to Liberia six times or something.

[break]

Q: Can you tell me about this semen testing program?

CHOI: Basically, before this West Africa outbreak, we knew that men could have Ebola virus persist in their semen after they recover. By virus isolation, which is considered the gold standard in terms of determining infectivity, the longest was eighty-two days, but by PCR [polymerase chain reaction] testing, which is detecting the presence of viral RNA [ribonucleic acid], the longest was 101 days. People said, okay, after you recover from Ebola, men should not have unprotected sex for ninety days. Give it eight more days past the eighty-two. 01:26:00But then in March of 2015, there was a woman in Monrovia, and this is really towards the end of the outbreak. There were really kind of no more cases, but then all of a sudden this woman got infected and she died. When they did an investigation, they found that her only link to Ebola was that she had had unprotected sex with a male survivor. But that survivor was 199 days recovered. People really did not believe that was possible, but they tested semen on him and they were able to sequence the Ebola virus RNA in his semen, and they compared it to the Ebola virus found in the woman's blood, and it pretty much matched, which suggested that the woman got Ebola from having sex with this male survivor. This caused a lot of problems, because this is the largest outbreak in history. We have tens of thousands of survivors in all three countries, and also 01:27:00now, Ebola survivors and Ebola patients in general face a lot of stigma that's just made that whole situation worse.

In response to this, the WHO basically said that men should have their semen tested for Ebola virus and receive counseling and condoms and that sort of thing. Semen testing was not widely available in Liberia, and so the president of Liberia basically asked the partners and their ministry to start a semen testing program. People started writing up a little bit of a protocol. They said, this is the protocol, go to Liberia and start a semen testing program. I went in May of 2015 and basically worked to start a semen testing program, which was not easy. But by July, we were able to work it out. Basically, at the time, 01:28:00what we did was we started at Redemption Hospital, which is in Monrovia. Monrovia has the largest number of EVD [Ebola virus disease] survivors. It's also the most populous city in the country. We based our program there. We have a little office there, and we made semen collection rooms, and basically all men fifteen years of age or older who can show some proof of survivorship, which is usually a discharge certificate from an ETU, are eligible to enroll. Basically, they come, we explain the program, we counsel them about safe sex and these whole issues about protecting your partner. We teach them how to use a condom, and we give them free condoms, and then we ask them to produce a semen sample. Then we'll test the sample, and then give them the results in about two weeks. Those people who get two negative tests in a row can graduate. They really 01:29:00wanted a certificate--they're kind of into certificates. So they get this little ID [identification], basically a certificate, that basically lists the dates their semen was tested and the results and has their picture on it so they can't be forged, and they get that as their graduation. For the ones that continually test positive or whatever, they continue to come in and receive counseling.

At this point we have expanded, so now we have three sites. We have one at Redemption Hospital in Monrovia, another one at another hospital in Bong County, and then another one in Lofa County, and these are all three counties that are highly affected by Ebola. Then we also have a mobile team. The idea was there might be some people who don't want to come to the hospital, whether it's they don't like the hospital, maybe they have bad associated thoughts or feelings about the hospital, or they don't want the stigma associated with coming. Our 01:30:00team will go out to wherever they want us to meet them, usually their house, and we will provide the same services that we would do at the clinic at the house. We collect a semen sample from them as well, and then we'll test it, and they'll get the results.

Basically, the program has been running since July of 2015, and it's been going well. I think at this point we have 470 men who are enrolled, three hundred some have graduated. We have people that are still testing positive, which is unexpected. When we first started the program, we honestly had no idea when it would end, but we thought for sure we would be done after six months. Even at this point out, we have men who are continually testing positive, so we've had to continue, continue, continue, but it's always been a little bit of a 01:31:00surprise. We just figured everyone would test negative by now, but they're still testing positive. Again, it's by PCR, so all we're detecting is a presence of viral RNA, but we don't have the capabilities to culture semen in-country. We're honest and up front about that. We tell the men, just because I detect it doesn't mean--I don't know if it's alive or dead, but out of an abundance of caution we're going to assume that it's alive and you should adhere to these precautions until it's negative.

Q: Precautions probably being--

CHOI: Abstinence or condoms.

Q: There we go.

CHOI: Yeah. Exactly. Which it's been kind of a good experience. We get feedback and people are pretty grateful for the program's existence and the fact that they're able to know their status, basically.

Q: Do you guys give away condoms?

CHOI: Yes. We have lots of condoms. We give away a lot of condoms, yeah.

Q: Cool. There's a few things I'm interested in, and one of them is that time in May. First, you went to Liberia in May 2015 and were kind of scoping it out and helping conceptualize the program and set everything up. Is that right?

CHOI: Yeah. I went in May to start it. I didn't leave until July.

Q: You didn't leave until--okay. And you said that that was a difficult time. What made it difficult?

CHOI: It was kind of a lot of things. First of all, we had two--there was already a proposal kind of written, but we had to in a way rewrite it because it had to fit within the context of Liberia. Getting people on board was a really 01:33:00big deal and a big problem. In the beginning, I think they thought I could do this in a month, set up a whole program in a month. But it takes a lot of work. We had to write the proposal, then we had to submit it for non-research termination. We then had to--where are you going to have this clinic? Are you going to open it up with MSF? Maybe take one of their rooms and do it with MSF? Are you going to do it with ELWA [Eternal Love Winning Africa Hospital] clinic? Where are you going to have this clinic? Where are you going to find these people to work? How are you going to recruit these people? How are you going to do this in a way that's not stigmatizing? It was just a lot of work. We worked with the Ministry [of Health and Social Welfare], we worked with WHO. We would 01:34:00have three hour meetings a day to get everything started. Like trying to figure out the space. Then once we got the space, we had to renovate the space. Then we had to build the semen testing rooms. The mental health capacity in-country is very limited. Finding counselors to counsel our clients was difficult.

In the end, what we ended up doing, we didn't want to reinvent the wheel. What there was already existing--we wanted this program to fit with what was existing. That's why we decided to set it at Redemption Hospital, because it's a public hospital--so that once we built the capacity and this is over, if two or three years later there's another Ebola outbreak and the semen testing program needs to come back, the capacity stays in-country. The counselors we used are mental health counselors that normally work at Redemption Hospital. So again, in 01:35:00a couple of years, if something happens, they're right there. They've been trained. That was really important to us. Training locals. Not bringing in expats [expatriates] to fill these roles, but really training the locals to do it so that the capacity stays in-country. But that takes a lot of work. Honestly, it's much easier to do it the other way, because you're like, okay, I'm just going to bring someone that can do this and I don't have to train them.

Also, developing the training materials, developing the counseling materials, what are you going to say? Nothing has been developed for Ebola before. We were really lucky in that the Viral Persistence Study in Sierra Leone had already been going on. We borrowed heavily from their materials. But again, we had to adapt them for Liberia, and there were other challenges. Where are we going to test the specimens? What laboratory? How are the specimens going to get there? 01:36:00How are we going to store them? What is the paperwork like when you send specimens to the lab? All these details, you have to figure out. It took a lot of time.

Q: Were you the main person on the job?

CHOI: Pretty much.

Q: Was there a small team from CDC?

CHOI: I was sent with Kristin [E.] Vanderende, but then she was only there for a month. And I'll be honest with you, the person who was in-country at the time, who was part of the country leadership at the time, did not think that starting a semen testing program was a full-time job. When I got there, I realized this is going to take much longer than I thought. I asked them to backfill Kristin with somebody else, but they told me it was not a full-time job and that I could do this by myself. So it was very hard. Right before she left, this person who 01:37:00objected left, her replacement--the first thing that this replacement says to me is, "You need someone to backfill Kristen, I'm working on it right now." I never even said anything and she came up to me and this is what she said. Kristen left, but it was too late to backfill her. I ended up having to--just whoever was there that wasn't busy basically ended up helping. It worked out actually quite well, but it was challenging. But yeah, we had a small little army, and it was really, really necessary.

Q: After that point, once you guys start rolling, are you one of the people who is seeing people coming in, or are you administrator? How does that evolve?

CHOI: Honestly, I thought my only job was to start it and then leave, which I 01:38:00did. I started it and then left. But then it was like a sticky ball because it never really left. I was like, I guess this is still mine. When there are lab issues or whatever, it still comes to me. I honestly didn't think I would still be doing this a year later. We send people, other people, once a month from CDC from all walks of life, and it's been pretty amazing the group that we've gotten to go, but I'm still somehow involved. But there's been a lot of turnover in terms of staff within the WHO and the Ministry, so having some people who have the institutional knowledge of why we did things the way we did is kind of helpful, so I guess I can see that. We have this whole army of people going, but 01:39:00I'm still involved.

Q: Who are some of the most important people from, say, the government in Liberia who you've worked with?

CHOI: Our program director is a person named Moses [J.] Soka, and he's a physician in Liberia, and he's phenomenal. The guy is super, super smart, and he really drove--because a lot of--we had to get administrative health buy-in, and it took a lot of work. We had to jump through a lot of hoops. Dr. Moses Soka, he spearheaded all of that. I relied heavily on him and the WHO person who is also Liberian, because I have no idea where to find pools of people who could be a data manager or a counselor or anything like that. They were responsible for 01:40:00finding all our people. Basically, they're like, "I know this person, this person, this person who's good, they have a background." We would get all these people--they would review their CVs [curricula vitae] and they would select the ones that came to training. Then we would do the training. Then we would together select who we were going to hire. But that kind of in-country knowledge of bureaucratic procedures, just how this country works and the labor force and what's available, one hundred percent was Jomah Kollie from WHO and Moses Soka. Without them, we clearly--I mean, we kind of had the technical stuff, like how we were going to do it and what lab and that sort of thing, but really it was the human resources, all the kind of nuts and bolts, getting it done was all them. It really was a team effort.

Q: Has your effort on the Ebola response really for the last year been focused 01:41:00on this? On this semen testing? Or have there been other little things that you've been--

CHOI: Pretty much, this has been it. I dabbled in the infection--

Q: Not that it's not enough. [laughs]

CHOI: --yeah, no, I doubled in that infection control stuff with New York and Dallas, but at this point it's primarily the semen testing program. There's other things that are coming up where there's a National Ebola Training and Education Center that has been stood up by ASPR [Office of the Assistant Secretary for Preparedness and Response] and CDC, and so we're trying to get more involved in that and being more involved in the education and that sort of thing, but it's been primarily the semen testing program. Just trying to keep Liberia Ebola free.

Q: When's the last time you went to Liberia?

CHOI: I was there in April.

Q: A couple of months ago?

CHOI: Yeah.

Q: How was that trip?

CHOI: It was good. I did have a rather eventful trip before that. There was a colleague who was ill, so we helped take care of him. So the last trip was very uneventful, which was very good.

Q: I know it's a long span of time I'm asking, and this is kind of a ridiculous question, but any memories that happen to stick out, stand out in particular, from your time on this study?

CHOI: On the semen testing program?

Q: On the semen testing program, excuse me.

CHOI: The thing I've always been impressed with is our staff. They're very dedicated to their jobs and they understand the importance of what they do. We recently had--when I was last in Liberia, we brought together all the counselors 01:43:00to talk about their challenges and counseling patients and that sort of thing. Just listening to--because I'm not a mental health counselor--just listening to their approach and their dedication to the clients. They had one person who basically said, "I'm not joining," and was rather a difficult person about it. The counselor said, "Okay, that's fine. I'm available. Let me know," and would call this person and see how they were doing and that sort of thing. They've really gone way above and beyond their job duty. It's because they really believe in what they're doing and they really care about these survivors. Every time I go there, I must say, that's the thing that I'm most impressed with is the dedication of our staff. The program is a success because--and our retention rate is so good because of the level of attention that they provide, and it's 01:44:00real. It's not they're just doing it for whatever. They're doing it because they care.

Q: I want to ask, is there anything else that we haven't gotten to yet that's about Ebola or your life that you'd like to get on record?

CHOI: No, no, I think that's it. [laughs]

Q: Okay, good. It was pretty comprehensive. Thank you so much for being here. This has been a pleasure and very educational, thank you.

CHOI: Thank you.

END