Sara Hersey

Sara Hersey

Q: This is Sam Robson here today with Sara Hersey. Today's date is June 1st, 2016, and we're here at the CDC's [Centers for Disease Control and Prevention] audio recording studio at the Roybal Campus in Atlanta, Georgia. I'm interviewing Sara today as part of our CDC Ebola [Response] Oral History Project. So Sara, thanks so much for being here with me today. You've traveled a long way specifically for this interview and I really appreciate that.

HERSEY: Oh, sure. Two days just for two hours, yeah.

Q: Definitely. Can I ask for you to pronounce your full name and your current position with CDC?

HERSEY: Sure. It's Sara Hersey and I am the CDC country director in Sierra Leone.

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

HERSEY: June 30th, 1972 in Rochester, New York.

Q: Did you grow up in Rochester?

HERSEY: No. Short term. Dad moving, so most of my life was spent in Hershey, Pennsylvania.

Q: Tell me about that.

HERSEY: Do I need to? [laughs]

Q: You don't have to, no.

HERSEY: No it's fine. My dad was transferred to the Hershey Medical Center there so we all sort of got in the bus from Denver, Colorado, and moved to Hershey when I was quite young. Spent a lot of time there but it was never really kind of home. My family is still there but I don't really use it as home. So it was fine but interestingly enough, a lot of the outbreak responders that we've seen for Ebola came from central Pennsylvania. We had a huge swath of them at one point. Just everybody seemed to have come from that area. I'm not sure if it drives people out [laughs] or there's just a unique spirit of adventure of people that actually live there.

Q: I can identify with the desire to go out. I grew up in central Iowa, so yeah.

HERSEY: Okay great [laughter].

Q: So what kinds of things were you interested in growing up?

HERSEY: Not science. So I came with sort of a strange roundabout route. I was 00:02:00very much a humanities person. I love to write, outdoor stuff, you know. Definitely anything that was more kind of humanitarian--hands on, volunteering. Ended up in this sort of weird path on my way to science from Peace Corps--doing Peace Corps in Malawi right after college. An English and Italian Medieval and Renaissance literature degree was my first step on my way to CDC. So I don't really have like the classic CDC path that many people take. Went from there to Peace Corps and was one of the first HIV [human immunodeficiency virus] volunteers in Malawi in the late nineties. Got very excited about public health. Had worked at Planned Parenthood for a long time before and then just kind of routed into the science side of it into epidemiology. So each step ended up a 00:03:00little bit closer to CDC and a lot closer, I guess, to doing this type of outbreak work that we did over the last--two years I guess. Yeah, it's been a long time.

Q: Can you tell me any vivid memories that happen to surface when you think about your time in Malawi?

HERSEY: I was there twice. I was actually there with the Peace Corps and so that was my first overseas. I had lived in Italy before but I'd never done like the real kind of overseas non-European experience. Then I was there again I think with CDC, so it was my first CDC posting as an epidemiologist. I think my most vivid is the contrast between the two. I was in Malawi in the days before ARTs [antiretroviral therapy]. I was an HIV volunteer. It was the day before ARTs existed. It was working in a hospital with really nothing that you can do except sort of compassionate care. You know, caring for people while they're dying, hoping that you could find something a little bit more concrete to help them in 00:04:00a lot of helplessness. To going back a couple of years, or nine years later, when the ARTs were available, when there was treatment for HIV and it was just a complete transformation of the country. I think probably my most vivid is the biggest commerce in the country in the late nineties were coffin shops. And going back in the late 2000s they barely existed. I mean there's still high levels of death but not in the way that it was a viewable commerce everywhere in the country. And I remember just that change was really striking to me.

Q: When you came out of Malawi for the Peace Corps you subsequently went to public health school?

HERSEY: Mm-hmm. Yeah. After I finished Peace Corps, I helped start an NGO [nongovernmental organization]. The DC [District of Columbia] Campaign to Prevent Teen Pregnancy was one of the Clinton initiatives. Some old colleagues of mine from Planned Parenthood were starting that, so I was an intern. I helped 00:05:00them out in [Washington] DC for a couple of months and then I went to Tulane [University] for public health school. That was where a lot of--that was a good hub for people who were just coming out of Peace Corps and I just sort of found international work and realized that that's what they wanted to do. So I studied epidemiology there and complex emergencies in Tulane. Also I was not ready to go back to the United States, so I did decide that New Orleans was not really the United States. It was New Orleans and it had a flavor all of its own, so it was a really good landing pad. A lot of international people in this kind of zany, exciting environment with really good academic, but kind of a good social spirit I guess I could say at the same time. Yeah, so I realized I wanted to stay in international work, that really Peace Corps kicked it off for me.

Q: No doubt. I would've imagined you talking about your work in HIV/AIDS in Malawi and like Planned Parenthood and in DC, focusing on reproductive health. 00:06:00But your focus in school was on--what was it again?

HERSEY: Well, I did epidemiology in complex emergencies. So I had started public health not even realizing I was in public health as an HIV counselor back in college and then working also with battered women and sort of worked my way through all of the different iterations of public health. It was very much community public health and Peace Corps. I came out of that, I was doing more of the NGO work and I was doing the operations side of things. And then when I went to do public health school, I had actually done so much HIV work and I was so burnt out from sitting in a hospital for two years where I felt like I really could not do that much, to wanting to do some really hard science. And then realized that the more of the community science piece, while I enjoyed it and it was useful, it wasn't really what was speaking to me. So I went back not quite knowing what epidemiology was and decided to retrain in epidemiology. Obviously, 00:07:00my English degree wasn't going to get me too far in public health or not in the scientific side of public health, so I retrained in infectious disease epi [epidemiology]. And I was really interested mostly in looking at complex emergencies, so malnutrition, food and waterborne illnesses, that type of thing. I really wanted to get a cross section of infectious disease work that I had not had before and with the intention of actually going to work in complex emergencies, so civil crises primarily which I ended up kind of eventually getting my way to. I think I've always liked doing the public health but public health in chaos, and that seems to be a growing field of people. A lot of people who didn't realize they like doing it until this Ebola outbreak where a lot of new people, a lot of domestic people or people who hadn't really done just kind 00:08:00of what the crazy emergency looked like where I was kind of used to doing it in a crazy environment. So it really kind of spoke to me.

Q: Can you talk also a little bit about moving from--it sounds like maybe you moved--tell me if I'm wrong--from focusing on individuals to the population, looking at populations as a whole.

HERSEY: Yeah. I think for me sort of that transition in public health--I'm not quite sure where that shift was. When I decided I was going to be an epidemiologist, I didn't actually know what it was until--it just seemed right. It's like me doing a demonstration of how to put a condom on under a mango tree was great I guess for someone maybe even if just the laugh factor of it in Malawi, but I'm not sure that was the way that I was going to make the biggest impact. It just made so much sense to kind of look at what community and population-level impact you can have rather than looking at the individual side. Because I don't come from clinical training I think the epidemiology training 00:09:00kind of had more of that big picture. So I sat in my first epidemiology class and I went, aagh, this is right, this is for me, I'll go dust off those statistics books because I haven't used those for a while. Great training that I got. Ended up going right back into HIV after my training. So I did STD [sexually transmitted disease] and HIV surveillance in Southeast Asia for five years after I finished my master's.

Q: What was that like?

HERSEY: Interesting. It was kind of a combination of luck and also just being willing to take risks. So I did have a job. I had two contacts and I packed up a bag because that's all I owned and I moved to Thailand with about a thousand dollars to my name--and that was a loan from my parents--and a big school bill. And I ended up getting an internship which turned into a local hire pay which 00:10:00turned into a consulting contract which turned into a job sort of in a six-month time span with an NGO called FHI, Family Health International, or FHI-360, they've re-branded themselves recently. And I was adopted by an amazing group of epidemiologists who--CDC didn't have as much of a presence at that time, particularly the PEPFAR [President's Emergency Plan for AIDS Relief] didn't exist. I'm way before PEPFAR. It didn't exist. There weren't these huge pots of HIV money. A lot of the funding was coming through USAID [United States Agency for International Development]. So we were the NGO arm of USAID that did a lot of the HIV and STD surveillance and they just kind of adopted me, trained me and threw me into the field and said, let's see if you'll bounce. And I did and I loved it. So I realized I actually was an epidemiologist at that point. Before, I just said I've got some training but I'm not quite sure if I'm going to be able to apply it. And when I got there, I did and I was so fortunate. By the time I was twenty-eight, I was managing surveillance systems in five, six, seven 00:11:00different countries, covered all of South and Southeast Asia for five years. Lived on the road. I probably traveled, probably did about seventy, a hundred trips a year. I mean all regional, so just jumping around but sometimes I'd do two, three countries in a week. Really got my passport bulked up at that stage. So that's how I ended up in epi and just realized that it was really where I wanted to go. So when I joined CDC, it was with the HIV group because that's the background that I was coming from.

Q: Absolutely. What years were you in Southeast Asia and then what year did you come to CDC?

HERSEY: Well, there's a big gap in between.

Q: Oh, sorry.

HERSEY: No, it's--so I did '99 to 2005, I was in Southeast Asia with Family 00:12:00Health International. And then I left there to go to London School of Public Health [Hygiene] and Tropical Medicine. And while there--while working on the PhD that I'm still working on [laughs], I started doing real work in complex emergencies. So I was working with UNHCR [United Nations High Commissioner for Refugees] primarily, also World Bank. I was helping to design surveillance systems for populations affected by conflict, mostly refugees, a lot of internally-displaced war--countries that were at war or countries that were unstable so the traditional surveillance systems didn't really work. So I worked a lot in South Sudan, I worked in the border of Uganda and DRC [Democratic Republic of the Congo]. Lebanon. I helped to support a lot of projects that were happening in other areas. So I was based out of London but I was just kind of running around the region, mostly Africa, trying to implement these and get some 00:13:00standards set for how do you do surveillance but doing it with populations who are very mobile or at risk or have been displaced from their homes primarily by war. So that was two and a half years.

Then from there, I started getting a little burnt out on that. And also coming in and kind of cleaning up decisions that other people made, and I wanted to go back, and traveling, I was just tired of traveling. So I wanted to get dug into something that was mine. I remember on the same day about seven people sent me a posting that CDC Malawi was hiring an epidemiologist and it just was a perfect fit. So that's how I got into CDC. So not the Commissioned Corps, MD [medical doctor], EIS [Epidemic Intelligence Service] route at all. But I have been overseas for almost twenty years now so I bring that side of it, the unconventional, international side to it. So that was my introduction into CDC. 00:14:00And then, of course, when I got there I was the epidemiologist but I was also asked if I'd like to manage the laboratory program when I landed. I was uniquely unqualified to do it but I did learn [laughs], not having the laboratory, sort of the bench lab side of it but having the program side of it. Each of these positions you just kind of grab what you know and try to apply it to a totally different side or a different field of work.

Q: Do you remember what year it was you went to Malawi as the epidemiologist?

HERSEY: In 2007.

Q: So what kind of work were you doing as an epidemiologist primarily in Malawi?

HERSEY: The bulk of the work was HIV. HIV and STDs. It was really PEPFAR country East and southern Africa. Sometimes you forget because we've been inundated by HIV for so long, but it is extraordinary the public health problem that it 00:15:00continues to be. We were mostly doing HIV work. So we were doing antenatal clinic, so pregnant women and general population surveys, looking for prevalence. We were doing incidence surveillance, drug resistance surveillance, a lot of different modeling, a lot of reporting. Because PEPFAR is about reporting [laughs]. And at that stage, because we were a very small country and we grew very quickly. So I know people have talked about like the introduction of PMTCT [prevention of mother-to-child HIV transmission] [Option] B+. It was just like a different model of if you are pregnant and had HIV, you just immediately went on to treatment. And it was kind of the first step, sort of the grains of it started in Malawi and this has happened a lot where the transition of HIV is the earlier you find somebody who is HIV-positive and the faster you put them on treatment, the better it is both for them but also for the risk of 00:16:00further transmission. So there was a lot of programmatic stuff that was coming out at that time that was all built on epidemiology and science, but it was that translation between the epi and the program. And so that's when I started kind of getting more into how do I pull the science pieces together with the programming, better programs, more efficient programs.

I sort of have continued doing epidemiology but started to move psychologically I think more towards doing programming and management because I liked bridging those gaps a lot. And sometimes that's--in a very scientific organization like CDC, sometimes you can get very--and I admire the scientists who can just get dug in into one topic and be just a genius about it. I was much more interested, because I understand the science, in how do you bring it over to a program? So that has definitely been one of my big focuses. And there's not that many 00:17:00opportunities to do it where--at CDC we fund--we have our own money, we set our own mandates in terms of--well, obviously working with others and working with host governments, but we can help to find our own strategic direction and we can do sort of the core scientific piece. Many other jobs you're either begging for money and writing grant proposals and you finally get that and you can do the science, or you are handing out money but you don't get to do the science. And this is like a great combination of the two. It's a pleasure to be able to do that. Not very many opportunities to do that particularly with the federal government.

Q: Absolutely. How long were you in Malawi?

HERSEY: With CDC, I was there for three years and then two years prior with Peace Corps. So I've done five years. I've lived there longer as an adult than I have in the United States [laughs], so it's kind of second home for me. After Malawi, I was in the South Africa office for a little while. I needed some 00:18:00infrastructure in my life because I was getting a little tired. I was doing strategic information and prevention as an epidemiologist in South Africa, which is an enormous program and it was a different face of it. Malawi had very little funding and a lot to do, whereas there, we had a lot of funding and it was how to best implement it and how to best influence the direction of programs with funding but bringing the science into it at the same time. It was a very different atmosphere. It didn't speak to me as much. I like getting my hands really, really dirty and I don't really care--so I prefer sort of the smaller programs where you're very hands-on with it, you have to make a lot happen with a smaller amount of money to go around.

Q: But you'd said that you wanted more--at least to try more of the infrastructure. Is that right? What did that mean?

HERSEY: More of the programming side.

Q: Oh. Okay, sorry.

HERSEY: No, more of the how do you--that translation, sometimes they call it implementation science or the translation of science to effective field programming and that's what I wanted. I didn't just want to be the science anymore. I wanted to be that kind of link, so moving towards the programming piece.

Q: So South Africa was helpful in that respect?

HERSEY: It was helpful in that respect. Plus actually it was very helpful in getting to understand CDC. Like how do you move money. Just all of the bits that are associated with the management and operations of how do we fund partners, how do we manage funds, how do we do oversight, how does an office work. Every office I've been in--I think there because we had so much money, it was really quite an eye-opener about how do you manage that amount of money. So yeah, I was there for about two and a half years I think, two or two and a half years.

Q: Ending?

HERSEY: What year are we in right now?

Q: We're in 2016.

HERSEY: Okay, so I got there in 2010. I left in 2012.

Q: For what?

HERSEY: I became the South Sudan country director. So I got back to my roots. Having had that sort of CDC training, I really wanted to go back into something that was a little bit more chaotic. So there are a lot of crazy jobs in this agency but that's one of the craziest ones and it was fantastic, really fulfilling. I loved South Sudan. I had worked there before. Obviously, a complex emergency just coming out of a long, long war. You know, two years of independence when I got there. Actually it wasn't even two, it was about a year and a half of independence. You know, world's youngest nation and really like a small country program but one that had so much potential to grow and so much 00:21:00need in the country. The public health needs there are just devastating. So I ended up there for--I did two years there. A little bit broken up by a large outbreak of a civil war and a wartime evacuation which closed our office and had us all on C-130s with the military getting out of there as quickly as possible. It was a really scary time actually, especially to leave our staff behind. Most of our staff were local staff and so we can't do anything. They were trying to evacuate their staff. We had just built--we had a real movement I think in our country program of expanding it and building it up. Amazing staff. Good relationships with the government which is not that easy to do. And then just hubris, ego, politics, just everything erupted. That was in 2012--no, sorry, I 00:22:00can't remember. Three years ago now, so yes, December 2012 because it was about two weeks before Christmas when the war broke out and one of the pockets of fighting--it was not directed to the US government. One of the pockets of fighting was right off of our residential compound so we were definitely at risk. Did a lot of duck and cover, a lot of safe havening, a lot of lying on the ground while--a lot of trying to calm family down and trying to figure out how to get out of there.

So we had to abandon the program for a while, but amazingly, our local partners were fantastic and the program kept going. Some of it was not any planning done on my part or our colleagues' part but the war was concentrated in an area where most of our programs were not. There was enough stability in some parts of the 00:23:00country that we could keep essential health services going and actually was able to scale up. Plus we got our staff back and then I got back again about six months later and we were able to scale up in the middle of the war and after the war with incredibly poor supply chains and real--a lot of fear, obviously. A lot of wondering what was going to happen next. A lot of issues here, not just at CDC Atlanta but in Washington of, is it worth the investment? Because it could just blow out of the water. And showing it's a small investment but even if it's hard, it's still worth doing. And I think that was what everybody said, we can still do this, and ultimately scaled up the program the following year, which was pretty good. I'm looking forward to--I think some of our staff are going to be here next week. Seeing everybody, seeing how it's going. But it was a really 00:24:00rough ride but it was what I signed up for so you kind of know what you're getting into when you move to South Sudan. It's not going to be the smoothest, but I got back to my roots. It wasn't a lot of money but it was definitely everything that you did had a really significant impact. You could just see it. Even though you felt like you were just fighting through things half the time. But a lot of people with really good intentions both in the government and out. It was the highest tier of the government that really, really took the country down.

Q: Were you there when the Ebola epidemic erupted in West Africa?

HERSEY: I was. Yeah, I was just being pulled back from ordered departure when things started. They had actually said I would go out in one of the earlier [groups] going out, and then there was at one point a question about whether they were going to clear the CDC office to go back. Not Atlanta but Washington. 00:25:00A lot of the decisions were made at the State Department and the White House level. The larger the footprint we had there, the more it sort of seemed that perhaps the US government, while various close allies with South Sudan, we certainly weren't condoning what was going on and also it was very, very dangerous for staff so they wanted to keep the footprint very small and so there was some negotiation to make sure that CDC remained part of the footprint. Ultimately we were and I was just going back as Ebola started to become a really present problem.

So that was in July when I went back. And then August, September basically I said I'm absolutely willing to--I think at that time we weren't quite sure--we didn't know that this was going to be as long. We knew it was big but we didn't know it was so big and so very long. I'm still having people tell me it's going 00:26:00to be over by June and it's still not over. We're still having cases. So I said--we were going to pull down--at the anniversary of the war, we were going to pull down staff anyway. It was quite a dangerous time. So I said, I'll give up--give me a couple of weeks plus I'll take my Christmas, my New Year's and I'll go out, and I went out on TDY [temporary duty assignment] to run the epi. So I went from December and January, I was the epi team lead through that. I went straight from Juba. Just thinking, you know, Juba's here and Freetown is just to the left on the map, but a twenty-nine hour trip across much of Africa and half of Europe, finally got me to Freetown which was very interesting.

Q: What's that route?

HERSEY: It's not easy. I've done it a couple of times. There is nothing simple about it. I mean a lot of it was the airlines were closed down. So whereas you might have been able to go in through Kenya Air, only Brussels--[Royal] Air 00:27:00Maroc. But like the real international big carrier was Brussels. There were not a lot of options to get into the country at that time, so you kind of just hit whatever connector you could get until you finally made it into Freetown and the boat that takes you from the airport. I'm sure you've heard stories about the boat, but I just thought--it took me I think four flights, a boat and a little duck-and-cover in South Sudan trying to get out. This is a really, really interesting trip.

But I went out for a couple of months saying let me help, it's a downtime for us anyway, it's dangerous in the country, I don't want my staff there. It's a good time for me to be out if I'm going to do it. I think everybody kind of had to negotiate. It was not easy even with a call from Dr. [Thomas R.] Frieden's office to put your staff in. I had a lot of international experience and I worked emergencies, so I was ready to go and help out with whatever people 00:28:00needed. Still, it was a negotiation to get out there. I gave up--it was a year and a half before I had a holiday, through a war and through an Ebola outbreak, because you gave up all of that time and then got out, as we all did, and ended up--I think I went out initially for six weeks and then negotiated more time once I got out. We were all doing that. I can't tell you the number of supervisors I hit up to keep staff on. Actually worse though were the significant others. Like I will write a long heartfelt note to any really, really good response person's significant other asking them for the pleasure of their spouse's company [laughs] for a couple more weeks, because that rotation thing just killed us. I know everybody is complaining about it. It set us back. It set the entire outbreak back.

Q: I would love to hear more about it from you because I haven't heard as much as I expected to have heard.

HERSEY: It was rough. I was negotiating with my own supervisor. I think a lot of 00:29:00us had to act like we were being given a favor to be out in like the worst outbreak scenario that CDC has ever responded to our entire lives, working sixteen, twenty hours a day nonstop. You know, it wasn't a holiday. There was a big disconnect between like what is a crisis with a small "c" and a Crisis with a capital "C" that requires the more intense on-the-ground capable people you have early. It just changes the course of everything.

Q: And a crisis with a small "c" being?

HERSEY: South Sudan. Well, no, there was a war, but it wasn't as though I was going to be able to change the war. But a public health outbreak--not me personally but our agency, that's what we're mandated to do. Or a PEPFAR COP, you know, a country operational plan, like another strategic plan. I get it, but 00:30:00at the same time there's always going to be another strategic plan. I think there was a balance. I understand why there was a problem with that.

So I did a TDY. I started as TDY and then when I was over there in January, I had interviewed for the country director position and accepted it while I was out on TDY. So then we kind of went into the negotiation of switching me over. I started taking on some of those responsibilities while I was out in Freetown the first time on TDY.

Q: What do you remember from that first six weeks or so that you were there? You said like December, January. What were you working on?

HERSEY: I was the epi team lead. We had about, somewhere around twenty epi's, twenty to thirty depending on the day. Sometimes some science people, too. Spread out I think in seven different districts. There's fourteen districts in 00:31:00the country. So at that point the epidemic had moved where it started in the East and had started moving west and right before it got there it really hit Freetown, which is the urban center. So I know people had heard about Monrovia and Liberia. Nobody had managed, except for Liberia, an urban outbreak of Ebola before and that was going on when I came in. And about I think ultimately 60% of the new cases, 70% of the new cases, happened in Freetown or in Western Area is what it's called. So that's what was happening when I got there. Just really--I mean we knew what we were doing. We know how to do Ebola but not Ebola on that scale and not Ebola without a single epicenter but just spread all over the country. With the amount of resources that it required, the staffing that was required, even just the pure logistics behind it were just amazing.

Contact tracing was just falling apart, absolutely abysmal and that was sort of--if you can't do contact tracing, you can treat all you want and that's wonderful but you're just going to have to keep treating and keep treating. And contact tracing was just not--part of the problem with that is doing that scale of contact tracing and the amount of data management that that requires and individual management it requires. It had been sort of outsourced to a UN [United Nations] agency, not WHO [World Health Organization], that didn't do contact tracing because for some reason I think the UN wanted a little equity. So each of the UN agencies got a little piece of the outbreak response which everybody agreed later that it was absurd. We had UNFPA [United Nations Population Fund] trying to run contact tracing. And when you've got one outbreak which we saw later--so when we started having clustered outbreaks that we could really keep eyes on, we knew what we were doing, like we were tight. But not 00:33:00when you have--we peaked at five hundred cases in mid-December in one week which is a lot more than any outbreak total that we'd ever seen anywhere.

I think one of the things, too, I realized when I got in is everybody had been so "you just do what's in front of you" and there'd been so much of just kind of responding to crises and responding to crises. We had a ton of data that we were not using that we could've been using to make good and fast and relevant decisions. Trying to dial it back from--data wasn't for your MMWR [Morbidity and Mortality Weekly Report] when you got home and data wasn't for necessarily publishing--well fine later, but right now we can look at this and make a decision, and what are we going to do tomorrow with this data? And I think that was one of the big things because that's kind of the background that I come from. I don't come from more of an academic science background. It was like, 00:34:00where are we taking this science and what are we going to do with it, and what are we going to do with it right now? So that was really what my focus was when we were there was to make better-- have a much better understanding of what was going on. Trying to anticipate where we would need people, where things were working well. Understanding what was happening there, trying to shift things around, dealing with the local politics, dealing with the constant turnover of staff, dealing with--some really good science was going on in the country including a vaccine trial, but there was also a lot of people had sort of some scientific agendas. I'll say that's something that was really problematic, is I just didn't care what their scientific agenda was. Like there are certain things that we need to do now.

And then some people just bloomed. Like people who never had done something like that before. Kind of wondering when you looked into their eyes when they got off the boat whether they were up for it and just phenomenally--and others just 00:35:00went, this is not for me. It was scary. I mean there was still a lot of fear about infection of our own staff. Like a lot of fear. So in any normal circumstances my worst fear would be a car accident and my worst fear was a staff member getting Ebola. So we were pretty vigilant about things like antimalarials and please just try to stay away from anything that might mock the same early symptoms of Ebola because you do not want to end up in an Ebola treatment unit. And I think the fact that CDC agency-wise did such an amazing, amazing job throughout West Africa and there were no infections, is really actually an extraordinary achievement. I think we had something like a thousand deployments plus by the end of it, even more. I do feel kind of badly especially on campus here because I had so many people come through and I really don't know 00:36:00all of them. It's not my normal management style, I don't know if they've written a book about how to do this. So I just smile at everybody and nod and sort of look friendly and act like I know who they are [laughs]. Yeah. I don't always do that. Often you'd realize they didn't know who you were because you were just off in your world and they were going straight out into the field.

So I moved over straight from--I went back and closed up in South Sudan and ended up transferring in early April I think, as the permanent country director.

Q: So you went over there and you never came back in a sense.

HERSEY: I went back to South Sudan for two months.

Q: Oh, for two months. I missed that.

HERSEY: In between. And when I had to go back to South Sudan, close up, get the country operational plan for PEPFAR written. That was just one of those like Crisis or a crisis--[laughs] a little bit resentful of that. But I loved my team 00:37:00and I also didn't want to leave my team in South Sudan because they were so wonderful. I didn't want to abandon them but there was so much to do in Sierra Leone. I mean, what a lot of people said, it was exhausting but it was one of the most satisfying things we've ever done, especially if you get sucked into process-type stuff every day or having lots and lots of meetings where you're parsing like should we use this word versus this word. And there, especially if you're an emergency-driven person and you could see who are the ones who did emergency work, you know, you're just on. Like it is make a decision and go, adjust as you go, do not doddle, to not overthink it, use the best science you have, apologize if it didn't work. And I think we did a really good job of it. Certainly not--didn't always feel like it but I think in the longer scheme, CDC definitely had a really strong role to play in the epi, the science, the labs, all of those things particularly working as counterparts with WHO as well as 00:38:00with the Ministry of Health [and Sanitation].

Q: What were some of the big decisions that you remember making, or little decisions that were still important your first time there?

HERSEY: I remember coming in, the acting country director told me--who I worked with closely for years so we had a good collegial relationship before I came in.

Q: Is this Oliver [W. Morgan]?

HERSEY: Oliver, yes, and he had name requested me to come in and this is because--basically you got there and you started hand picking the people that you knew and you trusted. Where you asked the people that you knew and you trusted who did they trust, and that is how we got some of the best people, particularly the international people. So I was told my top priority was to shut the viral hemorrhagic fever database down and to streamline the surveillance system. He wanted an overhaul. At one point it was taking us five days and 00:39:00serious, like four data management staff just to get an epi curve. It was a mess because the VHF database, the viral hemorrhagic fever database was--and everybody will tell you this--the people who designed it, the people who used it--it was designed for a very different Ebola outbreak. It was designed for one location with close data management but we had fourteen sites. All of them we were trying to bring in and synchronize data into a central location and there were different versions of it everywhere. We maxed out the capacity for the program itself, so--I think Epi Info can only take x number of files and it just crashed. And I thought, I can't even do an epi curve. How am I supposed to use this? So I understood Oliver's frustration with it and we just kind of went through an assessment of what we have. We got some informatics people out, like emergency phone call to Atlanta. like get him on a plane, I need hardware and 00:40:00software people now or you'll never know what's happening with this outbreak. And decided forget it, we're keeping it, it is the devil that we know and I think we can fix this. And we did keep it open. Oliver will probably be really angry with me for using this anecdote but I'll tell him about it later. But we did keep it going and we now have--we are the only country that has a full longitudinal database of the entire epidemic.

Q: How did you make it work?

HERSEY: Oh, I was not the genius behind making it work. I just made the decision to do it. Just got some really like solid people in. They were just running around, they were fixing bugs, they were updating versions, they were hand holding, I mean just to send files and synchronize files. And then we had some amazing data management people. Sometimes I think a lot of times with science people forget that data management is just as critical a need as the statistics 00:41:00side of it. It's just like how do you handle large data sets. They did a phenomenal job. And so I think keeping that going and then starting to like really use that data was one of the--probably the first big decision I made that went against everything else that everybody told me. And I was like, well, I've never worked in like a multi-site Ebola outbreak before. And their response was nobody has, so you just have to make the decision that makes the best sense to you and that's the decision that made the best sense to me. So that was I think the first decision that I made.

A couple of decisions to repurpose or not use some staff that just didn't understand what it was that we were there for and what their responsibilities were. I think we all had that. A lot of HR [human resources] decisions. I think almost 40%-50% of our time was spent trying to find staff and trying to find 00:42:00good staff and trying to make sure that they were oriented and they knew what they were doing, they were safe, they were reporting so we knew what was happening in the districts. I mean all of that stuff was a huge amount of work.

A lot of time spent working with the front office, the embassy and making sure that they were part of this outbreak and they really knew what was going on and they were able to be our policy face, which we've talked about this a lot. But maybe if you're in a rural area with a small outbreak of X, Y, and Z, you don't need to know how does an embassy work or even how does CDC work or all of that stuff. You just go out there and you have to know how the science works and hopefully work closely with the host government and the local population, and that takes a lot of doing. But this was a policy endeavor, not just a scientific endeavor, so it was good. We've all talked about it afterwards, having people who were country directors before who had done this kind of stuff.

We were also setting up a program and a country office in the middle of an outbreak which is something I think we've all agreed is probably not the best thing to do both at the same time just from a mental health perspective. I do think it helped us with the government. Like the government in Sierra Leone really trusts CDC, and one of the reasons is they really trust Tom Frieden a lot. He was in very early and spoke very frankly and he was listened to and I think he made a big, big impact in his early visit. And then he had three visits throughout just really hammering home to the government how important this was and just keep that going. I think no other agency had that level of person that was coming into the country and saying this is important. I think maybe we had 00:44:00like Margaret Chan fly overhead once with Ban Ki-Moon--but nothing like really with the people. He brought that, and then I think CDC saying we're here to stay, setting up a country program, keeping staff, trying to keep staff a little bit normalized so they kept seeing the same faces over and over again. That brought a lot of trust from the government and without their trust it was impossible to work. So there were obviously a lot of moving pieces happening. I just ran into a bunch of colleagues here who were country directors or out doing response team leads and when we talk about or think, I have got PTSD [post-traumatic stress disorder]. Like I don't even know if I can--especially having come from South Sudan straight to Sierra Leone, I think about it and I'm like I just don't know how I'm still standing. But we did it so far [laughs]. It's not done yet so the worst is over. Hopefully the world has learned to never 00:45:00let an outbreak get this out of control again, though when you look at how Congress is responding to Zika, you wonder if they really have learned that lesson.

Q: No doubt. Was it early on--I actually don't know when the decision to create like a CDC country office in Sierra Leone was made. Was that while you were there?

HERSEY: Oh, yes, early and some of it was that the Global Health Security Agenda countries, so the three Ebola-affected countries are phase one GHSA countries, so the understanding was that we were going to develop GHSA. So we actually wrote a country program strategy in January 2015, which was right after we hit a peak of five hundred cases a week and we were starting to come down. We still had a massive outbreak and we were doing strategic planning at the same time, 00:46:00which ultimately was good because we were able to transition a lot of our work pretty well. We haven't had sort of the "oh, outbreak is over, okay what do we do now?" Like we have really transitioned like the lab work, VSPB [Viral Special Pathogens Branch] had a great laboratory in Bo District. CDC tested over a third of the samples during the entire outbreak for the country, but based in one of the districts. We were able to transition that more to reference laboratory capacity, system strengthening, you know, things that--CDC doesn't normally run a lab. So now we're trying to do more of the systems and the accreditation and the quality control and the oversight and management. It's not the easiest thing to do but the same with the epi. You know, we might not be doing active outbreak investigations but we're setting up and actually funding the system that is supposed to be the early warning system, the integrated disease surveillance and 00:47:00response. It's called IDSR. So we're really heavily invested in that and we started investing in it back in January or February to make sure that this doesn't happen again. If that had been working, we would not have seen the Ebola outbreak that we did because we would've had early reporting and they would've known how to report it. Villages knew that something was wrong, but there's no way--you know, either it's the translation, is it a disease or does it have another cause. If there is an unusual event, how do you report it, to whom, and if they find out about it, what do they do? So none of that was really in place and in other countries--I mean I think South Sudan could've handled an Ebola outbreak. They had Ebola but they could've handled an Ebola outbreak better than Sierra Leone because those systems were there. Not great but they're there.

Q: I had the great opportunity, one of my first interviews was with Regan Rickert-Hartman who has now joined you guys.

HERSEY: Yay! Yeah, she just landed permanently in Freetown on Friday so she's 00:48:00leading our communicable disease surveillance program. She's one of our best.

Q: I know she has the IDSR experience.

HERSEY: Yeah. There are some superstars. I would say Regan was definitely one of them. But there are four of us that kind of ran--some from the very, very beginning to the end. So me, Oliver Morgan. Did you--

Q: Mm-hmm. I've interviewed him.

HERSEY: Sarah Bennett, yes, also and then John Redd.

Q: Also.

HERSEY: Okay, so the four of us, we feel like we're the ones that--the Sierra Leone kind of core four. And we just had our wish list of who were the best and who do we want, especially some of the people that haven't had as much international exposure. It's hard to break into the international field, or do you want to. And we have been so fortunate. We've had the [unclear], they're on staff. We've got a phenomenal team and it feels like a family because I was very clear--our first thing, requirement of our country office is not our program, 00:49:00it's outbreak. So we just got tested two months ago when we had a new case of this woman, bless her, traveled--very movious, as we say [laughs]. So she was in four different locations, infected two of them, one possibly two with wet symptoms, still trying to trace that down. So we're looking at four different geographic areas where we have to launch an outbreak response and because we had so many great people who are kind of part of the family now and on staff or always on TDY, we were able to just step down our whole program and just step up a four-district outbreak investigation in twenty-four hours. So yeah. We're prepared now to do it with the resources we have. So yeah, great people. We've got some fantastic staff. Yeah, lucky.

Q: I'm going to take us back for just a second. I know that you're undoubtedly 00:50:00used to it, going from one thing to another for the past, as you said, your adult life, right?

HERSEY: Yeah. Someone wonder whether I'm an emotional adult yet, but yes. [laughter]

Q: Oh, come on. So you're probably used to just like getting up to speed really quickly on things, but what was it like for this specific response learning everything you had to know?

HERSEY: I broke like every cardinal rule. I'm used to just kind of you land and you go but you listen for a long time, especially when our counterpart is the Ministry of Health. We are the Ministry of Health of the United States. So I will never go into an environment and start issuing orders to somebody in another country. I've not worked in this disease area before because I hadn't worked with Ebola before. I don't know the government, I don't know the partners. And I was having to make decisions on the airplane on the way in about 00:51:00staffing and who was going where. It was difficult. Very, very difficult. You flew by instinct a lot more and a lot of it like for staffing was people would ask me by email, so what am I going to do? And I said basically you're going to land and I'm going to look you in the eye and then I'm going to make a decision. Because you could just tell who was up for anything, who needed some monitoring, would be a good worker bee but should probably not be making decisions, who needed to just get a data set and sit in the corner and please don't ever see the light of day. Because there are fantastic people, but there's a cross section of everybody and this is not an easy environment to work in. So I was making a lot of fast decisions from the science point of view. I mean I obviously try to know as much of the science as possible but we were learning 00:52:00every single day, so trying to keep up on the science to make those decisions. I'm used to kind of landing and going but not like that at all. And a testament to the CDC with all the rotation that we had. We had great relationships with the government when I arrived. And these were from people who were rotating every twenty-nine days. And then the government partners not thrilled about that obviously, but we have some great people so at least they got really good people to work with even though they then disappeared. It helped that--I think because from a senior leadership point of view Oliver was in in November and then I came in December and so either of us were like the sort of senior leadership faces of the outbreak throughout. That helped a lot because the government as well as the embassy knew who was making the decision and who to go to. It was one of the two 00:53:00of us and not somebody different every twenty-nine days, and that I think the other country offices did not have that. They had a lot of turnover in response team lead and acting country director for a long time. It makes me really tired just thinking about it [laughter].

Q: Can you tell me about an instance when that rapid turnover really you thought affected your response in a negative way? Just like one specific time and just talk about that.

HERSEY: Yeah. We had a really--it was when the outbreak was waning but we were having pockets, quite large clusters, and I think people were just tired. It was already hard to get responders but a year into it people are tired. They're not hearing about it in the US as much so they don't quite understand the urgency. We had a really bad outbreak in one of the wharf areas in Western Area, and I've 00:54:00been overseas for almost twenty years. I have lived in some of the worst conditions and I've never seen living conditions like this in my life. Like horrifying. Urban slums in the rainy season. I mean just awful, awful. And we needed staff to manage that and we had basically--somebody had put out saying they need numbers, not qualified people. And I watched, I just watched this group of people come off the plane, average age of maybe twenty-three. Some of them had gotten their passports to come. Young, super enthusiastic. Some of them with zero common sense. Like one of the things I did learn how to do is to manage the twenty-somethings. I had not worked with the Millennials before. I had not direct managed the Millennials. I learned a lot that way. But they were going into an urban outbreak, horrible working conditions, dangerous with 00:55:00community pushback. And I just thought, oh my God, I just don't know what to do with this, this is dangerous. The first thing I did is I turned off the "just send anybody." Just stop it, just stop it. We're name requesting from now on. I was so lucky because I had--John Redd was the Western Area lead then and I will never forget. I called it "make way for ducklings." John would walk through the Radisson [Blu Mammy Yoko Hotel] and there was this string of little twenty-somethings just following him in like a little-- [laughs] just waddling behind him and he was like the leader and I just thought, oh, if I didn't have somebody that I trusted to look out, just to guide them but also for their safety, I would've sent every single one of them home, just without question. And I don't think we had enough of the leadership people that we trusted. Like we needed good, solid people who could argue and stop and guide and be really 00:56:00kind of trusted and mentor, but mentor in the middle of a crazy kind of apocalyptic situation. Not a lot of people have that temperament. People who did not have the temperament to follow were put on a plane home. I had a very, very low tolerance and I probably have a lot of people throughout the agency that are not fond of me and I don't care because one of the things I was saying, it's not your right to have done that. Really it's not a right for you to be out there. It is not a luxury because it wasn't that nice. But, you know, it's my right to make the decision about who was going to be there and I did send quite a few people home. Not a high tolerance. Grounded a lot of people. I was very fortunate I had good counterparts in other agencies, so we would compare notes and if one of our staff was acting up, that person would be off that team and 00:57:00vice versa. And not always perfect. We did have a lot of struggles particularly with WHO in some areas. But at one point we were doing combined work plans where I would say "I've got kind of a weak person, enthusiastic but weak in this district, could you put one of your senior people there to pair with them?" And I would have somebody call me and say, "I've got somebody who's a little bit crazy and I need somebody really strong that can--like can you send one of your strong, strong CDC people out so that they can take over this district?" And that did not always work well but when it did, it was a great thing to have. So I think those were the types of decisions, like what do I do with you? Those kind of scary outbreak moments where you're not sure if the people--whether they--psychologically, I don't want to break somebody psychologically by putting them into a situation that they can't handle, but they feel like they're going to fail by saying it, and then also not having the time to really actively be 00:58:00able to listen if somebody is having a problem. So we needed more of those kind of senior people that could do that. So not enough, but the ones that we had were great.

Q: So what happens with Magazine Wharf, with that situation? I've spoken with John Redd a little bit about Magazine Wharf. So you have all of these inexperienced people coming in.

HERSEY: Did he tell you the same story about the same young group that he had in Magazine Wharf?

Q: Let's hear from you.

HERSEY: No, no, that was it. That was the "youngins" that he was helping to manage.

Q: Yeah, I just want to hear how it develops.

HERSEY: Well, no, that was his story to tell about how he did it, but for me it was like how do I, up here, how do I handle dangerous situations--

Q: And John Redd was your answer.

HERSEY: --with unqualified, enthusiastic staff, and that was the answer is the people like him, really having those like quality people. If not, we would've done so much more damage and we could've really gotten hurt. I mean we didn't 00:59:00have--we had minor accidents, we had no serious injuries, no serious accidents, no infections, not a single staff person who got malaria. Which I am going to take great pride in because I threatened people, I think it was beyond my ability to--but I just--we were not having any of that. Like you can't play with your own health in that kind of environment. And you're going to be no good if you're sick or if you have Ebola or if you're injured you can't help anybody else so you really need to take a step back.

Q: Am I right that there was some sort of change in like the CDC safety officers?

HERSEY: Ugh! Every month, yeah. I still don't know what the safety officer does. It's a good idea but it was so individual. We had some individuals who were just great and we had some individuals who had never been in an overseas environment before and were so--I'm trying to think of a nice word to use--a little bit 01:00:00overly enthusiastic about sort of counting heads and setting down rules and I mean just things that were painful. Whereas I needed somebody who could take care of our staff medically, I needed somebody who was really accountable, I needed somebody who was good in a crisis because we had a crisis all the time of some measure. We definitely medevacked [medically evacuated] people out or got people out for health reasons, but just not Ebola. Some of the things that we were being asked to do just didn't make any sense to me. I've worked in wars. If my diplomatic surveillance is--they are always conservative and they're looking out for us. Then when we are conservative about the health risk, which is absolutely what we should be doing, and then when we add like six more layers to it, it actually--we weren't getting the basics done from a safety point of view. I mean sometimes we were totally dependent on the person. I would love to see 01:01:00some sort of cadre of safety officers trained, scopes of work definitely with medicine. They don't all have to have medical backgrounds, but medical backgrounds in that kind of environment. So it was difficult. Very difficult. Sometimes worked for our advantage but sometimes it was just me managing back to a lot of field managing back to Atlanta. Lots of standing phone calls. I felt like I had the same phone call two or three times a week with me telling a slightly different group of people the same thing. I thought, could you just maybe take notes and distribute them, I just don't have time to do this. [laughter]

Q: When is it that you finally start to see the data coming in from the VHF database in a usable way?

HERSEY: I think it started coming in--I mean it was set up well before I got there, so I would say by probably October or November I think they were using it at a district level data.

Q: 2015?

HERSEY: 2014. Yeah, early, early. I mean it was definitely before--I got there in December 2014. So I definitely know that the early folks in who got that reporting system set up did a great job. I think the problem was it wasn't designed for what we were asking it to do. So then when I got there, data was coming in but we needed to work the gremlins out of it so that we could use it because it's not worth having a team of just twelve people on standby just to make sure that the dataset works. That's not a good use of people's time, so we needed to streamline it so that we could regularly use it.

Q: And you were saying it took maybe several days to get even the epi curve?

HERSEY: At one point. We got that fixed.

Q: The lowest point?

HERSEY: A very low point from a data perspective. I mean it had a lot of low points in different ways but from a data perspective, yes, that was the low point and we got that fixed up.

Q: So was there a point in February or March--I guess maybe you weren't there in March.

HERSEY: Yeah, I got back early April.

Q: How was the data situation at that point?

HERSEY: Much better. Much better, yeah. We had implemented routine data use. Some of it was because we were reporting to the director every week so we had a weekly call with Frieden and Dr. Frieden knows his data. He absorbs data like I've never seen anybody absorb data in my life. Some of it initially was because he was about to come visit and I had no data to show him. I had a huge dataset and just data floating all over the country and nothing to physically show him. Plus I needed it because I needed to show what was going on every day. Oliver needed it. We all needed this information, so we sat down with some great data 01:04:00managers and just said, let's get this going. And by the time he got off the plane we had our first data pack, which I think was like a hundred slides of data. And that thing just got bigger and bigger and bigger and weekly we updated it and used it routinely to make decisions and it was great. It was kind of routine data use. I definitely got in trouble from some of the other countries because then they asked Guinea and Liberia to do the same and they're like, we can't [laughs]. And some of it was because we did maintain this longitudinal dataset from the early, early days until the end. Those were the days. It was quite exciting but scary actually when we had no data to report. I just put up a blank slide with no data on it and said this is my new favorite slide because there was nothing to report. It was great. It was a great day I think for all of us.

Q: So when you come back in April, let's just take it from there actually. Can you tell me what happens once you get back in April?

HERSEY: I left because I wasn't physically on the ground but I had already taken over the country director duties at that time. I think it was more of a transition back into stepping out more of the technical role that I'd been playing because I've been doing a lot of the epi and trying to take on more of the management stuff. It was always a tension between, are we a response or are we a response and a country office. And I know Oliver, when he was acting, made it very clear like "I am the response lead." Like he was acting director and doing some of those things. He's like, I'm not going to worry about setting up your office. I mean he did some of it, co-agreements, partners, budget, all of that stuff. So when I got back, I took over trying to do what a whole country office might look like with all of--for GHSA primarily, plus doing a lot of the 01:06:00response stuff at the same time because then we were back to having rotating response team leads. And maybe it was a good thing. I know some people think it was good, some bad, but I was not going to let a twenty-nine-day person, even if they'd been there once a couple of months ago, be our face to the government. So I think I took on a lot more than the other countries of doing the response also myself, not just country directoring it, which was a huge amount to do.

Q: Like what aspects were you doing?

HERSEY: So there was the senior level coordination partner meetings, so head of WHO, head of the National Ebola Response Center, the NERC, which was the Ministry of Health--sorry, not the Ministry, the government side of it, Ministry of Health. You know, the UN agencies, UN [missions representative]. We'd meet three times a week in the morning for sometimes two, three, four-hour marathon sessions to do Ebola response coordination. Every Saturday night I had a meeting 01:07:00on that, too. I tried to be as active as possible on the technical side with Ebola response so that I was doing a lot of leadership with the different technical programs plus trying to get the country program stood up without a permanent deputy director. And I think it probably was not always the best thing because I couldn't be as present--I definitely know it wasn't the best thing all the time because I couldn't be present on both sides. But I thought the most important thing is that we maintain a single leadership person with our external and internal partners as well as with our internal team or it's just going to fall apart. If somebody had given me a great response team lead who said I'm here for nine months, I would've been like, hallelujah, I'm stepping out. But that was never offered. And then also some of the people, too, like if we had like a John come back or Sarah, they had tons of other things that they needed 01:08:00to be doing. So they were doing kind of hands-on like leading district teams, getting case management sorted out, that kind of thing. I couldn't have them jumping back in and out, so trying to do both of those pieces and trying to close out the South Sudan work that I was doing because I didn't have anybody come replace me for a long time.

Q: What were you still doing for that?

HERSEY: Country operational plans for PEPFAR, staffing, budgets, just trying to kind of be their point person because they didn't have anybody. We were a very close team there. That was an awful, awful time. Very, very difficult. I remember the first time I had a Sunday off. Didn't quite get the whole Sunday off but I took a Sunday off and it was just like this magical time. [laughs]

Q: When was that?

HERSEY: Oh, God, I don't even know. September, August--

Q: So you come in December of 2014 and you don't have a day off until--?

HERSEY: Nine months. I took a holiday at the end of September, early October that year and it was the first holiday I'd taken in a year and a half. Definitely no weekends.

Q: Let's also talk about the science part. You had mentioned that and STRIVE [Sierra Leone Trial to Introduce a Vaccine Against Ebola] and the difficulty of shifting between--we have a response right now and then the different objectives of STRIVE. How does that continue as you enter the country as a country director?

HERSEY: STRIVE with the vaccine trial, I know there were a lot of growing pains that started well before I got there and then also when I was there. They had 01:10:00worked a little bit more autonomously by the time I got there so I had to do more kind of the management stuff like management ops [operations], administrative things. Not like the technical side. But it ended up ultimately being a huge benefit both for the fact that we had over eight thousand healthcare workers vaccinated. And I don't take any credit for this at all except that it happened in the country that I was country director in. Huge research capacity, gave jobs to people like students when the schools were closed down, built cold chain facility. A better understanding I think with people who had never had exposure to research before about how do you do this and do it well, and it had a public health benefit. Like you don't always get that with research until twenty years later. So the fact that those could be coupled together, I think it was a great thing. I would definitely say there were many moments when Oliver and I were like, oh my God, I'm not sure that we 01:11:00can handle both at the same time because it put thirty additional staff onto our team. Just thinking about even pure logistics of that, that put a lot of pressure on an office that wasn't an office. But I think the lasting benefit of not just the information that's coming out of the trial itself but the capacity that was built in country was really, really good. Great people running that study, great relationships built, very impressive.

I think Sierra Leone, more than any of the other countries we had a large science portfolio. We had the viral persistence study that we did with WHO, a household transmission study that was done. A lot of, as you said, data. A lot of ability to do data analysis and triangulation that we're now building on. So for future--a lot of information for future use too. We're working on archiving 01:12:00as much data as possible for the benefit of the Ministry of Health, not of just kind of--I come from that, like, you can't just sort of do pure, pure research in the middle of all of this. Like if you're not using the information as it comes out--we're hopefully never going to see this again, so if you can help us stop it now, that would be fantastic. I almost never saw people trying to either sit on or worry more about what their publication ability was in a year's time versus I know something that can help you now and it might not be perfect but at least it will help put you in the right direction. We did see that in the viral persistence study, was very good about trying to get the data out quickly. I know the same thing happened in Liberia with the PREVAIL [Partnership for Research on Ebola Virus in Liberia] trials with NIH [National Institutes of Health]. That and testing our vaccine in the field in the middle of that, I 01:13:00don't think anybody's ever experienced that before. I would love to see us learn from what happened with Ebola for Zika so that we could start doing that now. A lot of moving parts going on. Ultimately we did--there were a lot of research interests in Sierra Leone and we said no to many, many, many different ideas and really were very careful to say let's try to do research at the same time. We'll never hopefully have this opportunity again so we want to take advantage of the opportunity to learn more, but if it doesn't have an immediate impact on how we manage Ebola and manage an outbreak, then it's not a high-priority research project. So that was kind of that was--if you don't hit those two, we're not even going to go forward. I'm sure there's great angst with people with their research hypotheses, but it was certainly not something that we were able to 01:14:00manage at that time. Even the fact that we did any research at all given what was going on was pretty miraculous.

Q: No doubt. So when you look at let's say the latter half of 2015, are there certain events or developments that you would put as like signposts for how the year developed?

HERSEY: I don't think in months very well so I have to kind of think in milestones. So that would be sort of June, July, August, September--

Q: Let's just stick with your milestones.

HERSEY: November milestone was zero plus forty-two, so I guess we could put it that way. I think we saw the peak in December of 2014 and then we started to see it going down in January. It was obviously a huge relief for us. It was following a natural epi curve. We were following very similar to what happened 01:15:00in Liberia. They started much earlier than us, so they peaked a couple of months earlier than us and we saw it go down. But then the tail that we had of small outbreaks that just kept popping up all over the place and just kept going and going in a couple of very difficult areas in the western area of the country. A lot of community resistance, a lot of political issues that we had to deal with and it just kept going. In Liberia at zero plus forty-two, granted they did it three times, and we were still having active transmission in multiple areas of the country. I just think we were just exhausted and kind of wondered at one point if we were ever going to get there or if it was endemic and we were just going to be looking at this forever. And I knew we would, but people were just tired. In the early days once we peaked, a lot of people were saying June. There wasn't betting going on but there was definitely trying to do some sort of 01:16:00forecasting and projection about where we saw the end of the active transmission. And many people were saying June. I remember talking to Peter [J.] Graaff at WHO, like these people have been doing this all the time and I said, "I don't see it anywhere before August, I really don't." I just remember this look on people's faces, they're like, August? Oh, it's going to be so far before that. I said August to other people and they were just like, what? And it just doesn't feel right. I just feel like this is going to keep going. That was nothing. It was November when we declared zero plus forty-two. So our last active cases were late September for the primary outbreak, so late September were really when there were cases. So I was still being very conservative and still actually more ambitious than I should've been and I think that just all of us were exhausted.

At zero plus forty-one--so when they declare the end of the outbreak, the last 01:17:00active case dies or leaves the Ebola treatment center negative, plus forty-two days. So two incubation cycles. And at zero plus forty-one, we had a scare where there was a positive--what was reported as a positive death swab from an area in the north that hadn't had cases for over a year and zero plus forty-one. I just will never forget everybody's heart just dropped. But it smelled funny like there was something--you've been doing it for a long time, you can just tell if things line up and nothing lined up. And it ended up being a sample that was inaccurately labeled. It was from breast milk and it was likely contaminated, the sample, when it was tested so it ended up not being a positive. It was great to see everybody got together and just kind of went through all of the information that we had and ruled it out within about two to three hours--not 01:18:00before it got picked up by social media. So a lot of that, like I hear you have a new case. I'm like, this is social media. Believe me, if I don't know that we have a new outbreak before you found out from Yahoo, then we have a serious problem. So at zero plus forty-one we were able to deal well with a scare and conclude that it wasn't a real case and go on. But I think everybody was just about to break at that point just thinking, oh, at least give us that milestone in November of 2015. We wanted that one milestone that said we had gotten there. That was a long, long road that we traveled and since then we've had one case likely from transmission from a survivor. That was in January, February.

Q: January of 2016?

HERSEY: Yes, it was January 2016 because I took a holiday and everything was very quiet and the person who was acting for me was like, oh, it's really quite here, it's kind of boring. And I said, well, that's why you're there [laughs] is to make sure that nothing happens. And a week after I got back from holiday feeling so much better, we had a new case and this was the one that was in four different districts. I think at that point we knew how to handle it. Politics were interfering, so the Vice President said that there were two cases and that the second case, not the index case, that it wasn't a true case. So the Vice President was saying something completely contrary because elections are coming up. I can't really put my finger on the politics of it. So the community resistance was coming from all over the place and had nothing to do with the 01:20:00fact that the Ministry of Health and the partners that were there knew how to handle the situation. We were just going up against political and tribal politics that we have no control over so that was very frustrating. But we were also very heartened to see that we can do it. Like this is a good team of people, both in the government and with partners, they know what they're doing now. Hopefully we don't have to test that too much.

Q: We're going to take a quick break.

[break]

Q: We're back from a short break. Sam Robson with Sara Hersey. I was just talking with Sara about how it might be nice to have a few more specific instances--specific memories of times, because we have a lot of really great broad strokes in here, that might help diversify it and give it some color.

Sara: Yeah. I think maybe just once instance that--and I don't even think he 01:21:00realizes he was involved in this--where all of my different worlds collided in a good maybe two-hour segment. It was in January [2015], and I had just accepted the country director position. I had never met Jordan [W.] Tappero who was to be my boss. I was with Oliver and I think somebody else--we went to the Guinea border to pick him up. So in the middle of introducing myself to my new boss, trying to manage this outbreak with not very strong field supporters out there so I was a little uncomfortable with what we were showing him. And all the different crazy that was going on and in a one-hour period I had to manage that, which is always nerve-wracking regardless of what situation you're in. I then got a phone call from our Bo lab team to tell us that they had just tested a positive laboratory sample in Kenema. Kenema is in the East, where there hadn't 01:22:00been any outbreaks for a long time, and ended up being a healthcare worker infection. So they, fantastic, called me immediately. So I was juggling because we didn't have any staff there trying to get word out to Kenema that they had an active outbreak in Kenema and that it was coming from likely a healthcare worker so there could be more transmission, and ultimately there was in that clinic. So we were trying to get that on. We got that stood up right away. About ten minutes later, I got a phone call from a friend of mine that was running Ebola treatment centers to tell me that they had a staff person who was incredibly sick. They thought she had Ebola. She just tested negative but she was really sick and they were trying to get her out of the country. They couldn't get her isolated, so they were trying to get her--knowing she didn't have Ebola they were trying to get her into Freetown. While they were bringing her into Freetown she was covered in vomit and her own feces and they were really, really worried about her. So they were trying to find a way to clean her up, get her into a 01:23:00safe place, get clothes on her. So it was just chaos and then I got another phone call from a deployer who I told not to do something many, many, many times and did it again. It was just like every five minutes, and I'll just never forget that because this was normal--three phones going. Something that happened that day that you would consider a crisis in any other world was five minutes of your day. And then having to deal--starting to get like another deployment out to the East and you're figuring out what was going on. It was just one of those like encapsulation--and I was like, "So, hi Jordan, I'm Sara, just give me a minute." It just was part of the crazy of everything that was happening at that time and really brought back to us--there were healthcare workers that we were constantly worried about getting infected and we were trying to support. I'm sure people have told you stories about getting evacuations done and things like 01:24:00that. Here, we were worried about, is this somebody we're going to have to evacuate for not Ebola but for another medical condition? Because other countries weren't able to--still weren't actively taking people in even if they knew that they didn't have Ebola. So there were just a million running parts and luckily this woman was severely dehydrated, somebody looked after her, either they were able to take care of her, we got her cleaned up, got her clean clothes. Kenema outbreak, launched an investigation there and multiple new cases. It just never stopped and that wasn't sort of your normal day-to-day work. Those were more things that happened and that was about fifteen minutes of my time while I was trying to introduce myself to my new boss. I won't forget that [laughs]. I don't know if Jordan realized what drama was going on. I was trying to be really professional at the same time [laughs].

Q: I'm sure you managed.

Sara: I'm about to see him. I'll ask him.

Q: That's amazing. Thank you for that. So let's talk about how the country office is shaping up now this year, in the last few months even.

Sara: I think we're in a really good place. I think the last three months it's come together. I don't think it was a smart idea to open a country office but ultimately we are so far ahead and we really capitalized on everything that we did during Ebola to move forward a lot of our objectives that would normally take us years to set up. I've been in countries that don't know what CDC is, so the first thing you do is you go to a meeting and you have to explain what CDC is. You don't have to do that anymore. Like, people know. Your average person in the village knows who CDC is. Which is actually kind of amazing because we don't brand ourselves. People have some hats, some people have some vests but it's not 01:26:00as though we've got our fluorescent WHO vests that we're running around in. Which, for better or worse--so capitalizing on that has been great. I think the fact that we're one of the Global Health Security Agenda and I have been through more government initiatives than I can count and I am pretty nonchalant and sometimes not super positive about them, but I have drunk the water on GHSA. I think it is the best thing that CDC can be doing internationally. It just has all of our core components. So we've moved that forward really quickly. We have our roadmap, we've cleared it, we've already implemented--like we're actually seeing progress, visible progress that makes me feel so much better when you see the country able to do something now that they couldn't have done without our support a year ago. So it's coming together. I'd love for us to be in an actual physical office. We are still living out of the Radisson Hotel in "the Cave" which is so named because it has no natural lighting and I'm sure OSHA 01:27:00[Occupational Safety and Health Administration] would absolutely die if they saw the way our staff were working. But people are--I think they're tired but give it a little bit of time and then I think they need some perks like internet and printers that work and some sunlight would be good also. So that's good. I think one of the tricks right now is actually--I think the two tricks are keeping morale going because we're not in a--it's always going to be a difficult working environment but we're still working under really bad conditions and you can only do that for so long. But we've got great staff coming in.

I think the other trick is what happens after 2017. This is going to be the question that we're all asking. We've been working on Ebola emergency funds. We have made a lot of promises, and we are in a great position to follow through on those promises, but we can't do it without money. So from a longer term point of 01:28:00view, where's my money coming from? I don't know. I think we're in a great position to be in one of the--kind of a model GHSA country, I guess you could say. I don't want it to be a PEPFAR which looms big to me in terms of just planning and reporting. It's got so many benefits but the amount of time and effort it takes to organize a program is a little bit beyond me. But if we could have an appropriation, I think we could do just wonders actually in West Africa and specifically Sierra Leone. Like there's something special about that place. I always said, "Sierra Leone, it's better than Guinea." That was kind of my [laughs]--but it's great. I mean people have really, really come to love it. I fell in love with it in December, in the middle of absolute exhaustion and trying to get my bearings and people were dying in the streets. Like you 01:29:00couldn't get across town. People were leaving bodies in the streets to show that the ambulances wouldn't come. They had a way of contacting people and saying somebody's died or somebody's sick and there's no way to pick them up--four days later people were dying. I guess because there's so many other things that are fresh in my mind I sometimes forget like there's just really horrible times that we were seeing. That's not going to happen again. We have the ability to manage that. I think if funding drops off or if people kind of--next year there's a flavor of the month and people sort of wander off somewhere else, it could happen again. There's a natural reservoir for Ebola. There's a lot of survivors who can transmit. There's a lot of other diseases wandering around that area of the world. So I think if people can keep their energy up, I think there's a lot 01:30:00of possibility. I'm excited. I'll stick around for a while.

Q: You said you fell in love with Sierra Leone. What do you love about Sierra Leone?

Sara: Well, I think the first thing is the view from my house in Juba was of a burnt out squatter camp, and the view from my room in Sierra Leone was the ocean and the beach and so [laughs]--and people were very excited. Like the Ministry of Health, the counterparts that we had were deeply dedicated and excited, and not everybody obviously, but I had great counterparts. There's just a vibe about it that just felt excited even in the midst of huge tragedy and I thought--if it's like this now, if I feel this way about this country now--like I get an immediate vibe from a country about whether I like it or not and granted I got an immediate vibe from South Sudan and loved it. So mine is not necessarily the 01:31:00same decision making that everybody else does but it just spoke to me. I just loved it and I just thought this is going to be the right place. So yeah, and here I am. Ask me again in two years [laughs]. It's got great beaches.

Q: I think that's actually a great place to wrap for this interview. Thank you so much for being here, Sara. It's been amazing hearing about your experience.

Sara: My pleasure. Nice talking to you.

END