Global Health Chronicles

Dr. Thomas R. Frieden

David J. Sencer CDC Museum, Global Health Chronicles
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Dr. Thomas R. Frieden

Q: This is Sam Robson here with Dr. Tom Frieden. Today's date is January 6th, 2015, and we're here in Atlanta, Georgia, at CDC's [US Centers for Disease Control and Prevention] Roybal Campus. I'm interviewing Dr. Frieden as part of the CDC Ebola Oral History Project. We'll be discussing his specific experiences as a leader of CDC's response to the West African Ebola epidemic. So Dr. Frieden, for the record, could you please state your name and current position with CDC?

FRIEDEN: Tom Frieden, Director of the Centers for Disease Control and Prevention.

Q: Thank you. To start off with, I'm wondering if you can describe your efforts around Ebola and other similar diseases from the time that you assumed the directorship of CDC up until 2013, so before the West African epidemic.

FRIEDEN: In 2009, I became CDC Director. We were immediately dealing with a very large outbreak of influenza, the H1N1 pandemic. That was a very challenging 1:00response. There was a lack of understanding on some parts that it was actually a severe viral disease, particularly for kids. Many more kids died that year than a normal flu year and there was a lot of disruption from it. That was a very challenging response because it didn't seem so severe to people and yet it was a severe disease. That immediately showed us how important it was to look for diseases that would come from anywhere. Nobody expected that the pandemic would've emerged, as it appears to, from Mexico. And that was one early indication of the need to strengthen our global early warning systems. When MERS [Middle East respiratory syndrome] emerged in the Middle East, no one would've predicted that MERS came from the Middle East.

So around 2011, I began designing an initiative called the Global Health Security Initiative and I pitched it to the White House. I pitched it to Denis [R.] McDonough; now he's the chief of staff for the President, then he was 2:00Deputy National Security Advisor I believe. He was very supportive, but he said basically I was looking for $3 billion. A billion and a half for us at CDC and a billion and a half for the Department of Defense, which they actually have, so they can use that as long as it's well aligned. I was looking for a $3 billion investment over five years. I talked with Denis about it and he said, "Doc, look at the Defense Department's budget, and when you see their budget, think big. Think real big." So there was an interest and a commitment to the idea of global health security, but we didn't have resources for it. We knew there were blind spots all over the world and we knew that a blind spot anywhere is a risk everywhere. This did get some traction, so we had global health security. There was a cabinet coffee. This is something that Denis arranged and others arranged. I don't think the President stopped in on this one but many other cabinet 3:00members did to think about global health security as an issue that all of us as a government had to think about.

Then in February of 2014, while Ebola was spreading but before it was recognized, we launched the Global Health Security Agenda. That's something that to launch something in the government, it's a year's production. So it was a lot of effort to get that to where it got to, and we were doing really a Hail Mary pass. We said we're going to help thirty countries with four billion people get better prepared and we knew we needed a billion and a half dollars for it that we didn't have. But I've always said that every well-conceptualized, well-written proposal will ultimately get funded, and that's what happened here. When we launched the Global Health Security Agenda, we actually mentioned Ebola in some of the op-eds and talking points as one of the things that we're worried 4:00about. But nobody expected anything like the Ebola epidemic that we experienced in 2014, 2015.

Q: Thank you for that. I'm wondering if we can switch gears very quickly and talk a bit about your experience of the Ebola outbreak in Nigeria.

FRIEDEN: There's no doubt in my mind that the moment of maximum terror was the cluster in Lagos. When we heard that a man with Ebola had gone to Lagos, this was absolutely horrifying. Lagos has a population roughly equal to all of West Africa combined: Guinea, Liberia and Sierra Leone. The amount of travel in and out of Lagos is about ten times higher than all of West Africa combined, and in Nigeria where--Lagos is a predominately Muslim city that has connections with the Muslim north, predominately Muslim north of Kano/Borno/Yobe where we'd been 5:00battling polio with tremendous challenges. I knew immediately if Ebola gets out of control in Lagos, it's going to be out of control in Nigeria, it's going to be out of control in Africa, it's going to continue not just for months but for years and it's going to kill people not just from Ebola but because Ebola is shutting down healthcare systems.

So this was July 20th, 21st. We had just activated our Emergency Operations Center on July 9th, and I basically grabbed people and I said, leave today or tomorrow, bring the people over from within Nigeria to the program, throw everything you can at it. And we then sent about ten people within the first two or three days. They were able to use the polio eradication infrastructure to address the challenges in Lagos.

[break]

FRIEDEN: I had to be on the phone regularly with the Minister of Health and with 6:00the governor of Lagos and I ended up speaking with Governor [Babatunde R.] Fashola multiple times a day for multiple days. The first conversation I had with him I told him--because he's a very highly thought-of leader in Nigeria. He had run Lagos, which is very difficult, very effectively for many years. Cleaned the city up, improved traffic, improved garbage disposal, improved lots of things. I said, "Governor Fashola, if you don't control Ebola in Lagos, the only thing you will ever be remembered for is the man who didn't control Ebola in Lagos. This is the single most important thing you will do in your time as governor. We will do everything to help you but we need you to play a leadership role in it." And he did. He was very effective.

So initially the team got there and it's all about organization. You organize an incident management system. So we replaced [an] ineffectual doctor with the 7:00deputy incident manager from the polio eradication program. He was very effective and he was running the programs very clearly. He had always been the deputy, so he kind of came into his own for this. A Nigerian who we had trained, we supported. Our own staff staffed each of the different units of the Incident Management System and in short order, they identified 894 contacts, they did nineteen thousand home visits to measure temperatures, they did forty-three Ebola tests that identified nineteen additional cases, and they stopped the outbreak.

During that time, we were so frustrated because they didn't have an Ebola treatment unit, and I said, you've got to set one up immediately, not fancy, right now. And there was a fight. They were going to use an old TB [tuberculosis] hospital, they were going to use this place, that place. Finally, Frank [J.] Mahoney and others from CDC went there. They found an abandoned building that was part of a medical complex and in fourteen days they built an 8:00Ebola treatment unit. It was functional, it was effective, it worked. But that slight delay meant that someone with Ebola left Lagos and went to Port Harcourt and started another cluster. That person didn't say they had Ebola. They ended up being treated privately by a doctor, and the doctor and his wife died. So they had to repeat that whole operation in Port Harcourt to stop Ebola there.

There's no doubt in my mind that if we hadn't stopped it in Lagos, it could've spread and changed from what has been a terrible epidemic to a true global catastrophe. The other thing that was clear is since this was happening in Lagos, and we'd already seen export to Senegal, it seemed that for every couple thousand cases you had at least one export, and we knew we were going to have tens of thousands of cases. So we're going to have dozens of exports of Ebola all over Africa and all over elsewhere and that was just such a challenging situation to deal with. The least understood aspect of this outbreak is how 9:00close to the precipice we were in that outbreak in Lagos.

Q: So it really wasn't just this theoretical "what if." There was a very real possibility that it could have jumped. It jumped from Lagos to that other town in Nigeria. It was something that was very tangible.

FRIEDEN: It could've been all over, and the other thing that really emphasized for us was the need to not isolate West Africa despite this horrible risk. The idea that if we just turn our back on West Africa, we're going to see such a horrible explosion that spread elsewhere will be inevitable. Someone at WHO [World Health Organization] used the unfortunate and incorrect phrase of, well, maybe it'll just burn out in West Africa. There's no way a disease like Ebola burns out. A disease like measles can burn out because everyone gets it and then it stops, but that's only in one community, and then it goes to the next place. 10:00So this idea that we had to both be careful about disease exports but not isolate these countries or it would make it impossible to stop Ebola there.

Q: Can you talk a little bit more about the difficulty of relaying that message, not just to the public but to other government officials?

FRIEDEN: It was really tough. I remember I happened to have a reporter spending the day with me and I had a phone conversation with Senator Mark [S.] Kirk. He was basically screaming at me, saying that I was being totally irresponsible, and I was using every argument I had, and I hung up the phone and the reporter asked me, "Did that work?" And I said, "It was like a ping pong ball against a metal safe." Just no impact whatsoever.

I then had an interesting conversation with the President about this. This is one of the many meetings I had where I was the guy in the videoconference and 11:00everyone else was in the room because I had to stay here running things and I couldn't be there with cabinet meetings that I was part of. So I ended up being a disembodied [head on a] screen a lot with the President. But in this meeting, I remember very specifically we had begun the process of establishing a closed loop. We were checking people when they left [West Africa] for fever, we were getting the information of people who were coming into the US. Customs and Border Protection and the Department of Homeland Security very creatively funneled people to five airports, which made it much easier. So we could track people when they were in, so if they got sick, they would rapidly be isolated and cared for as safely as possible. And we were discussing this because we knew that if we cut commercial travel, if we cut these countries off, it would be impossible to control the outbreaks and the possibility of real social unrest in the countries making any disease control effort impossible was there. In fact, I had a conversation with Congressman Tim [Timothy F.] Murphy in which I said, 12:00"Congressman Murphy, these are recently elected democratic governments. If they fall and we have dictatorships and war, believe me, I've tried to control disease in the midst of war, it's almost impossible." Well, he turned that around in a hearing and said, "You're coddling dictators." It really showed how difficult it was to try to make this point clearly to the public and politicians. We had this active monitoring system where there were closed loops so we could track people. This issue came up because--the President stood firm that we're not going to cut these countries off, we're not going to do a travel ban. There were calls for that from Congress, and it would have undermined our ability to stop the outbreak. So with this meeting they asked how it was going and I said, "Mr. President, I've been making this argument that unless we stop it there we can't protect people here and I'm getting absolutely nowhere with that argument. But there's another argument we can use, which is that if we cut 13:00off travel officially, people will travel unofficially, and then this closed-loop system we have of monitoring people actively when they arrive, we'll lose. And it will increase risk for that reason." It's the idea of instead of this longer-term concern--well if it gets really bad there, it will be worse here--that's a long-term thing. For a short-term thing, which is tomorrow if we stop this, we'll lose what we can do tracking people. And the President said--I don't remember his exact words but it was something very much like this: "Well, I may not know a lot about epidemiology, but I do know a lot about politics, and that latter argument is the only one you're going to get people to buy into." So that's what we did. They're both accurate. It's not dishonest to use either of them. In one of the very contentious hearings we had in the House, I kind of 14:00spelled out that second argument of having to maintain this closed-loop system, and one of the congressmen asked a very good question. He said, "Well, can you calculate how many people would come in illicitly," that would be a very small number, "versus how many people are coming in now who you might not diagnose promptly?" That was a good question, but fortunately it didn't carry the day and between the work that we did and the President did and Ron [Ronald A.] Klain did, we were able to not have a requirement for travel bans that would've been counterproductive and would've increased the risk to Americans.

Q: Can you talk a little more about the history of the decision to track travelers in the United States from West Africa, what all went into that, some of the discussions that you had?

FRIEDEN: I don't remember the exact dates, but roughly it went like this: We knew we had to reduce the risk, so the first thing we did was to set up exit 15:00screening in West Africa on a scale that had never been done before. When we looked hard at the data, we realized that the thermal scanners, these machines like X-ray machines you walk through, were not going to work. They had false positives and false negatives. If you're wearing a head scarf, for example, it won't get your temperature, and it will give false positives if you're a little sweaty or otherwise. So although they're used in a few countries around the world, that wasn't the right technology. So first we had to look at the different technologies and Dr. Nicki [Nicolette T.] Pesik did a great job rigorously evaluating them. That's what we do best at CDC, we rigorously evaluate the science. We realized that these infrared scanners that look a little like guns--you can hold it near someone's head, take a temperature--they were accurate and they were reliable and because of that, we put them in for all the people leaving. More than a half a million people leaving affected countries got screened with these, and we supervised to make sure the procedures were 16:00right. Initially it was pretty rough. In fact, the first time I came back from West Africa I was tested three times. Once accurately by the people we trained but then twice by other people, including the airline itself which wrote on my boarding pass what my temperature was, which was 32.3 degrees centigrade, which would have been dead. [laughter] So there were some roughnesses of doing it, though ultimately we did that well.

But then we realized, I guess after Mr. Duncan was diagnosed here, that we had to have a way of tracking people so that the moment they got fever we could safely shepherd them to a place where they could be cared for safely. And I thought to myself, oh, I know this, this is basically the kind of work I did in tuberculosis control where you identify patients and you track them every day. So this idea of having a care package and including a thermometer in it, we rapidly realized that a third of the people didn't have phones that worked in 17:00this country. A lot cheaper to give people a phone than to spend thousands of dollars trying to find them when they're not there. Phones are cheap. So this was really, I think, an idea that I had to establish a closed-loop system and make sure that we could do something that was a reasonable thing to do that was a middle ground between trying to stop all travel and doing nothing. And [it] did have a value because we found a lot of malaria, so we could at least get people promptly treated for malaria, and we could also resist the calls for a travel ban.

Q: I've recently had the opportunity to talk a bit with Dr. Jordan Tappero and Dr. Marty Cetron. Can you talk about working with them on that system?

FRIEDEN: This has been the largest mobilization in CDC history. About one out of every five CDC staff has worked in the Ebola response. At the peak, we had roughly 10% of our professional staff working on it. We've had fourteen hundred 18:00people go to West Africa, spending more than seventy thousand workdays there. Some of the people who impressed me so much were people like Tara [K.] Sealy, who ran the lab in Sierra Leone. That lab operated, I believe, for 421 days without a break. It did more than twenty-five thousand Ebola tests. It implemented robotics in the field to do high throughput testing. No one had ever done two hundred Ebola tests a day before. These are not simple tests to do. And it did it all in a great setting. I remember meeting Tara for the first time when I did a walkthrough of the Viral Special Pathogens branch in April and May. This is before the big explosion. She was just heading over there to set up a mobile lab, and when I met her, her screen saver on her computer was a picture of her baby. She was leaving her baby--I think her baby was about eighteen months at that time--the first time she'd been away. She was going for a month 19:00and she had her suitcase there. It was huge. It looked like one of those old trunks. It was the mobile lab. That's what she was going with. And she went on multiple occasions. I remember speaking with her Thanksgiving Day 2014 because she was there and I wanted to give best wishes to the team. She was there again I think on Christmas Day this year. And that team did phenomenal work.

We also had people like Kim [Kimberly A.] Lindblade. Kim, who was deploying from Thailand, ended up having important roles in all three countries. She got to, I think, Liberia first, and I met her there where she had helped in one area set up an effective contact tracing program. She then was in Sierra Leone, and we had a real problem with Sierra Leone. President [Ernest B.] Koroma insisted on mandatory quarantine of contacts. It was a mistake. It was a serious mistake and it resulted in contacts going underground and severe hardship for patients and 20:00contacts, and in my view, without a doubt extended the outbreak by at least three to six months. Now as a footnote here, I wish we had pushed back harder against that, and one of the reasons we didn't was this construct from the White House that the British owned Sierra Leone, we owned Liberia and the French owned Guinea. It never had any relation to reality in the field, but it undermined our ability to really play the lead role we should've been playing in Sierra Leone on policy issues because the British, since it was militarized, they didn't really get that that was the wrong approach.

Anyway, since we couldn't get that changed, what Kim and Oliver [W.] Morgan decided was they would create a voluntary quarantine facility, or VQF, and they would invite people from their homes voluntarily into that quarantine facility. That was important for people because what Koroma had ordered is that there 21:00would be a policeman outside your home if you were a contact, and that was immediately very stigmatizing. So it was quite popular with contacts to come into the voluntary quarantine facility, and we could take their temperature more reliably, we could give them enough food. My staff assured me, any of us would be happy staying here. It was a nice place for people, it wasn't a prison. So that was a very positive thing that she created and established there and definitely tamped down transmission in Sierra Leone. She then worked in Guinea, and she did some really perceptive analyses. I wish we'd done more of this type of work. It's what CDC does best. She looked and she found first off that most transmission was related to burial. So burial was causing a lot of the transmission. In fact, let me say that differently. The patients who died were much more likely to transmit than the patients who didn't die. It was about a five-to-one ratio. So that's important. That had immediate practical 22:00implications. That means if I'm doing contact follow-up of a patient who died, I have a high-risk contact here and I have to make sure I've got them all. The second finding she identified was even more important. It was that--Guinea had identified what were safe burials and what were unsafe burials. Well, there was no difference in secondary cases between safe burials and unsafe burials because, as the burial teams had been telling us forever, the patients were washing the bodies before they called the burial team. So that really emphasized the need to get people into the Ebola treatment units, that safe burial wouldn't be enough since it wasn't really safe burial. So Kim had this impact in all three countries.

Frank Mahoney deserves a tremendous amount of credit. He was there in Lagos, core to getting the response through. He was there in Liberia in September when everyone was just freaking out, and Frank just focused and said, we're going to do microplanning exercises with every county. And they called in, over the 23:00course of two weekends, every county leadership team: the elected officials, the medical people, others; and they said, alright, here's how Ebola spreads, here's what you've got to do. Now, let's do a microplanning exercise--which is something he learned from polio--on, where are you going to put patients before we build an ETU [Ebola treatment unit]? Where are you going to put contacts? And how are you going to do it? So all sorts of activities happening. Some of them not good. Some of them kind of vigilantism against patients or contacts. Some of them very good, supporting patients and contacts. But I believe that that community action, which was importantly triggered and supported by what Frank did, is the most important thing that turned the tide [of] the outbreak.

Frank reminded me of two things that I said in my interactions with him early on when things were just awful. I said, "Look. People aren't stupid. When they see people dying, they're going to stop touching people who have died from Ebola." And that's partly what happened. The second thing that Frank did is when we had 24:00the last outbreak in Liberia, this was the St. Paul Bridge cluster. And this was tough. This was really tough. There's a movie about CDC from the 1950's called Panic in the Streets, and in that movie the EIS [Epidemic Intelligence Service] officer--I'm going to spoil it for you--but in this movie, the EIS officer is there in, ironically, New Orleans, which is where Frank did his EIS program. But the EIS officer is called in because a man is shot and dies, and the assumption is that it's a murder, but the medical examiner says this man was not killed by the murder, he has pneumonic plague. He was shot at point-blank range and whoever shot him has now been exposed to plague. Unless we find who shot him and 25:00get that man isolated, there's going to be a plague outbreak in New Orleans. Well, the St. Paul Bridge cluster, one of their index cases was a man who was stabbed in the back with a knife and died--except he didn't die from the stab, he died because he had Ebola. And it was only because all of the deaths were tested for Ebola that they knew that. So they had to find the guy who stabbed him for the same reason, because there was blood all over the place. And this St. Paul Bridge cluster occurred in a very marginalized community. A lot of criminal activity, a lot of drug use. At one point on the regular calls--I had calls every Saturday with every country for well over a year--on one of those calls, Frank was in Liberia and referred to them as "the criminals," and I stopped him. I said, "You can't refer to them that way. They're human beings, we've got to treat patients as VIPs [very important persons]." Which is what I had said the first time--I had been there a year earlier. So they began calling them VIPs, and they made something like a voluntary quarantine facility for 26:00them. They brought them huge amounts of food, they played movies for them, and it was really the ability to engage each community that led to the ability to stop Ebola.

Q: I want to go back to something that you had said about the division of labor between medical humanitarian countries. You know, Britain with Sierra Leone and France with Guinea and [the] US with Liberia. Can you just actually give me a history of your interactions with other governments involved in the humanitarian response?

FRIEDEN: Early on, when the CDC model came out, we used that horrific idea of what would happen if we did nothing to galvanize action in the US government, and then I used it in a session at the United Nations with dozens and dozens of countries there to galvanize global action on Ebola and other areas. We wanted them to stop doing harm, to stop banning people, because we had local staff from 27:00other parts of Africa who couldn't respond because they wouldn't be able to go back. The British government did do an excellent job of running the response well. They put substantial resources into it.

[break]

Our largest contingent was always in Sierra Leone because that was where the biggest challenges were, and that was the case for well over a year. We had more people in Sierra Leone than either of the other countries. We were hamstrung a little bit by this idea that the Brits were in the lead, but we were able to generally work closely with them. The fact that they had militarized this did change some of the approach that they used. Guinea was a very different story. We really had challenges in Guinea. We were never able to field the kind of team, the size and depth of team we needed to implement as effectively as possible. Frankly--and this is immodest on behalf of CDC--I think the reason it took longer to stop it in Guinea is that we had fewer people there. Because CDC 28:00brings a level of quality that's just unparalleled in the world. But what was so encouraging about CDC activities in Guinea is that--when we put out a call for French epidemiologists, the French didn't provide anyone. In fact, they had someone there the whole time who was kind of professorial and lecturing and smart but didn't really do anything practically. The Canadians really came forward. They said, we've never deployed like this before, we've never done global work before, but we're willing. And they provided us with terrific staff, four or five at any one time, and that's continuing through March of 2016 at least. And they had a great experience with it, we did. They came down here to Atlanta to learn and then they deployed with us. They traveled in our vehicles, they were part of our team, and they ended up being team leads for many of the areas that we were working in.

The second wonderful thing was the Congolese, the epidemiologists we had trained from the Democratic Republic of Congo [who came to Guinea to help]. They were there, they're Francophone, they're from the rough region. They had a sense of 29:00it, and they did a terrific job. So we've had ten of them there at all times. I went to DRC for the express purpose of, first, thanking them for being such an important part of the response, and second, saying, couldn't we do more in DRC if you've been so effective there? We're still trying to follow up on that.

Q: Switching gears just a bit, I know that you were very active asking the White House to appoint someone to be essentially an Ebola czar to organize the general US Ebola response. Can you expand a little bit more on that and in your communication with the White House in general?

FRIEDEN: This was a really challenging response. You had stuff within the US going on, hospitals, transport, travel, you had stuff going on globally in West Africa and globally, you had the State Department, you had the Defense Department, you had lots of stuff going on. So from at least August, I had been 30:00pleading with the White House to appoint a czar because we were getting too many questions--and disorganization--[on] how the response was. I went [to West Africa] because I just felt I had to see it myself. I went in late August of 2014, partly because Kevin [M.] De Cock, who is one of the most experienced, seasoned public health/global health experts we have, who spent a lifetime in Africa, was clearly just imbalanced by the experience he'd had in Liberia. It was just so overwhelming. He had never seen anything like it and I felt I've got to go and see what can be done. It was a productive trip. I went with the goal of establishing incident management systems with an incident manager in each of the three countries. I was able to do that in two of the three. In Sierra Leone I didn't have enough time. I always felt if I had just had another day there, maybe I would've been able to get a much better doctor from within the country 31:00to run it so it would be from a medical rather than a military perspective. But that was successful.

I got back and I heard that the President wanted to speak with me. I'd just landed. So I got back around 1:00 pm on a holiday. I guess it was Labor Day of 2014, September 1st or 2nd, and I was speaking to the President at 4:00 or 5:00. So I was getting my thoughts together. I had written a trip report--I always do trip reports of what did I find, what do I recommend--and that trip report, I look back at it and it's just so frustrating. I said, this has to be done in weeks, this has to be done in days, this has to be done within a month. And it took a year to do many of those things. So the speed with which things were moving was very slow, and we had kind of a false start with the Department of Defense. Folks within DoD told us we can do anything. And we had, I'm afraid, magical thinking about what DoD could do. In July of 2014, I asked the DoD to 32:00build three hundred beds, one hundred in each country, and that would've been enough. But then they said, well, to do that we have to go through the DART [Disaster Assistance Response Team], which is USAID [United States Agency for International Development], we have to activate to activate the DART, you have to specify things. And we just basically got jerked around. I wasn't specific enough to say, "What I mean is build and staff and have them up and running within thirty days." Ultimately, the fastest thing they could do, they said, was in three months build twenty-five beds. I said, take it, do it and use it for healthcare workers. But the day I got back from West Africa, from my first trip, I talked with President Obama and I said, "We need to move very fast. The only group that can move this fast is the Defense Department." He said, "Well you know, they're busy with a lot of other things now." But ultimately, he came down here just two weeks later, September 16th, and made an announcement that all of government would be involved, the Defense Department would be involved, though not in a direct care role. And that September 16th announcement was very 33:00important. In fact, the US Ambassador to Liberia, Deb [Deborah R.] Malac, told me that that was the turning point for Liberia. Once the President said "we're in," there was hope again and they were able to really get people to focus on the things that they needed to do to stop the outbreak.

When the cases in Dallas happened, it was a mess. We had to rapidly change our infection control guidance. We had unfortunately not prevented the second nurse from flying back from Ohio, which in retrospect, knowing what we knew then, we should've done. That's something that we should've done differently. The personal protective equipment recommendations, that's 20/20 hindsight. We had seen many patients before. We hadn't counted on the fact that Mr. Duncan would have two and a half gallons a day of diarrhea. We hadn't realized how intense 34:00the contact can be between US nurses and patients compared to Africa. And I hadn't remembered what my father told me which is, when you see how other doctors practice medicine, you realize how resilient the human body is. There are a lot of mistakes in healthcare. I myself got infected with TB working in a tuberculosis clinic. So infection control clearly needs to be better. But when all of this was happening--it was happening a month before the midterm elections--it was the lead story in the news. It was absolutely everywhere, and I think at that point the White House agreed to appoint Ron Klain, who did an excellent job as coordinator. It was seen by some as a dis to me or CDC and it wasn't. It was what we had wanted and needed to run this more effectively. And there was criticism that Ron doesn't have knowledge of health, and Ron was very clear, "I'm not making any technical decisions, I'm letting the technical people 35:00do that, but I'm making it easier." In his farewell event, I went there, I said, "When Ron became director--before he became Ebola coordinator, getting technical documents cleared through the interagency process was a long and painful experience, and after he arrived it was no longer long."

Q: Can you talk just a little bit more about your relationship with Ron Klain and how that evolved after he was appointed?

FRIEDEN: I want to go back to something about Lagos for a minute afterwards, but let me talk about Ron and the White House. When the President was here on September 16th, he met with all of our leadership and he referred to the call two weeks earlier and said, "Dr. Frieden was"--I think he used the words "a bit agitated"--on that call. And I was. It was really mind-boggling. I've worked in 36:00war zones, I've done work after earthquakes and hurricanes, I've seen starvation, but I had never seen anything like I saw in West Africa. On the one hand, it could look kind of normal. You drive through the streets, people are walking around, shops are open. On the other hand, you look below the surface--I went to the ELWA [Eternal Love Winning Africa] treatment facility that Doctors Without Borders, MSF, was running--they had 120 patients and one doctor. They had sixty corpses that they couldn't even remove. There were two people who had died that morning; they couldn't move the dead bodies out because they didn't have enough people to suit in and move them out. It's not easy. And so you have people desperately ill next to someone who's died who can't be removed. That's just an apocalyptic kind of experience. I said in an email which apparently made it to the President, "It's like scenes from Dante." From day one, President 37:00Obama was very forward-leaning on this. He understood it, he was totally committed, came down on the right side of all of the key decisions on issues of quarantine and travel bans and getting resources and including global health security in the efforts. Other people didn't want to include that in the funding request, but he insisted and it was in. Ron Klain was very effective at shepherding that through Congress. Congress said, why should we do that? He says, well, do you want to be the person we say, he vetoed, he didn't support it and now we have Ebola there? So Ron was very effective in getting that through Congress, and he was very effective at coordinating different people's activities so that we had less churn and more focus on getting things done. His focus was more US than West Africa, but it was helpful to have him there.

Q: Can you talk about--so after the collaboration between CDC and the US 38:00military was brokered in West Africa, how that relationship evolved and your role in communicating with generals and other people in the military?

FRIEDEN: The approach with DoD was to work through USAID. USAID, through OFDA, the Office of Foreign Disaster Assistance, had developed a MiTaM [Mission Tasking Matrix] process by which requests could be made of the military. I would say that that process didn't work very well for us. It was indirect. So I tell somebody else, they tell somebody else, they tell somebody else and then they ask if it's this, if it's this, if it's this. I guess maybe my expectations were unrealistic, but the kind of things that needed to be done in the timeframe that they needed to be done was problematic. People like Frank Mahoney can talk about that in more detail, but it ended up being--often what we need is small and quick, and we ended up with literally aircraft carriers rather than small, quick 39:00things. That said, the military's presence there was extremely important. They did good things, they trained people, they did important logistics work bringing things in, they built the Ebola treatment units, they ran laboratories which were crucially important, but the most important thing the military did was to give hope. They were a hope multiplier in West Africa and that was really, really important that people knew that we weren't going to abandon these countries.

I want to just double back to the Lagos experience. At the height of the Lagos outbreak, I had a trip planned to rural Kentucky with Hal [Harold Dallas] Rogers, who is the chair of the House Appropriations Committee, a good guy and very committed to an issue that's very high priority for us which is reversing the epidemic of opioid overdose. And I debated, do I cancel this trip? And he 40:00said, "You can cancel, no need for you to come because I know what you're doing is really important." I said, "That's okay, I'll be in phone contact with my staff all day. If you don't mind, I'll just have to step out a lot." And so I went with a satellite phone and multiple other phones. We were traveling these rural hollers of rural Kentucky, and I'd actually been there before. It's Pikeville. My first job out of college was doing work for the Appalachian Student Health Coalition. I had been there then, so they were surprised that I'd actually been in their community before, thirty-two years or something like that earlier. But I was trying to reach Governor Fashola and the Ministry of Health and I was often out of cell phone contact, and I had this satellite phone and it was out of satellite phone contact. So the irony was here I was in the US and the same thing that was so challenging to us in Africa--we didn't have cell phone coverage--was a problem here at that moment for me. But I was able to 41:00reach Governor Fashola repeatedly and we had multiple conversations each day and we were able to get the response working very effectively.

Q: I'm wondering if you can tell me a bit about--and I know we have limited time left--your work with private companies like UPS [United Parcel Service, Inc.] and drug manufacturers.

FRIEDEN: The private sector was terrific. They came forward and they said, how can we help? We've got the CDC Foundation. The CDC Foundation is our interface with the private sector. Very early on, we were desperately short of cash. We didn't have money to send people there. We didn't have money for travel. We practically couldn't buy the plane ticket to get people there. So early on, the Gates Foundation gave us, I think, $3 million and $5 million to just get us started. Mark [E.] Zuckerberg came forward and gave us $25 million that was crucially important. Paul [G.] Allen from the Paul [G.] Allen [Family] Foundation gave us $18 million to support emergency operations centers and other 42:00activities there. Ultimately the CDC Foundation raised about $56 million here, and it was really important to have that flexibility and speed that you don't always have within the government. Frank Mahoney made a point that is very important: that a lot of times a rapid action can head off a need for much bigger things. So it may be that I need $400 to rent a hall to have a training tomorrow and I need to be able to do that now. [Those] kind of rapid-response dollars [are] very hard to get, and we did some of that through the CDC Foundation. Ultimately we ended up with a rapid response fund that we had private entities through. UPS has been a wonderful partner for CDC for many, many years, and what was clear is that we needed transport in West Africa and there are no overnight mail services. UPS doesn't have services there. So the CDC Foundation said, what do you need most? We need jeeps and motorcycles, hundreds of them. And now you need to get them there. So UPS actually got a 43:00plane and moved the stuff into West Africa on a boat, other stuff there, and those vehicles were really important in the response. And there were many other areas in which the private sector was very important in the response.

[break]

Q: How do we know and measure CDC's effectiveness in West Africa?

FRIEDEN: Well, first, success is pretty straightforward in one way. Zero cases. And as of January 2016, that's where we are now. We don't anticipate that we'll always have zero cases, but we do expect that there will never be widespread transmission as there was in 2014 and 2015. And that, I think, is very important. But that would be insufficient as progress. What we really need as progress is the global health security work making sure that these countries and countries throughout the world have systems to find, stop, and prevent health 44:00threats as soon as they emerge, whether they're Ebola or a tick-borne illness or measles or another serious health problem. This is core public health. This is about finding a problem when it first emerges, responding rapidly and preventing wherever that's possible.

[break]

Q: I had wanted to ask a bit about the history of the decision to create these long-term country offices in the three worst-hit countries.

FRIEDEN: We realized early on that this was going to be a long response. In fact, I remember the President calling me. I was in the Emergency Operations Center. I got a call from the White House. Didn't know who it was going to be. Stepped into the incident manager's office, shooed everyone else out. It was the President, a few days after he'd been here, asking how things are going, what more he could do. Another time in the Oval Office he said to me, quote, "You're the man, you've got to tell us what you need, the whole US government is behind you to do this." But it's hard to identify what-can-you-do, because--I said, 45:00"Mr. President, you're doing all the right things, but this is going to take many, many months." It's so far out of control, it's going to take so long. And we realized that for the Ebola response, success required something very close to perfection. Success required being able to find every case promptly, every contact, every contact with a fever, every interaction with a person with a fever that might be Ebola--and we estimate that there are two million febrile episodes each month in West Africa--and then every burial being safe. So, so difficult to get that level of quality. Very early on someone said to me on one of the phone calls, "These countries in West Africa make Uganda look like Switzerland." And that difference is a real challenge. Going forward, what we've got to do is have high-quality, rapid, practical, sustained systems to find and stop health threats wherever they emerge.

Q: Can you talk a bit about the conversations you must have had with leaders in 46:00Liberia and Sierra Leone and Guinea about the long-term CDC presence?

FRIEDEN: I spent a lot of time with each of the three presidents starting with President [Ellen Johnson Sirleaf]. The first time I was there, I had to be very blunt with her in a private meeting, saying, "This is going to get a lot worse, it's going to get a lot worse before it gets better, but we will stay here. We will be here until it's over." And I gave each of the three presidents that as my commitment and we've kept that commitment.

[break]

FRIEDEN: We realized early on that one of the biggest barriers to responding in West Africa was the lack of trained staff here. So what we did for the staff here, Stuart Nichol and others realized that there was only one course to learn how to treat Ebola. It was in Europe. It was run by MSF. It was high quality. Let's replicate that here. And we were able, within a relatively short time, to replicate that. More than five hundred healthcare workers went through it and 47:00that resulted in much safer care in West Africa. We also had the strength in the system here. So even before the first case in the US was diagnosed, we had been scaling up the LRN, the Laboratory Response Network, for Ebola tests around the country. These are Ebola tests that both CDC and USAMRIID [United States Army Medical Research Institute of Infectious Diseases] have developed, and they're accurate. Having those available meant that patients could be diagnosed in hours instead of days. So we had the laboratory network there, and then, once we went to the system of having designated hospitals, we established teams to go out to each of the hospitals and work with them on really getting ready. And hospitals put a lot into this. They spent a lot of money, they had a lot of focus. Sometimes they did excessive or unnecessary things, but there was a real focus. It's very hard for people who didn't live through this to understand just how much panic there was about Ebola at the peak of it with hospitals terrified and 48:00the kind of risk. That's why for me it was so challenging. You had to modulate. On the one hand, to say, this is not going to be a big outbreak in the US, it's just not going to happen. I used the quotation in the news, "It's not in the cards." The way it spreads is unsafe care and unsafe burial and we can control both of those things in the US. Yes, we have to be really careful, yes, we have to invest and focus, but it's not going to be a big outbreak here. Even the day I announced Mr. Duncan's diagnosis, I said there may well be additional cases, meaning in healthcare workers or family members. But when there were cases in the nurses, it just got ratcheted up the next level. At the same time telling people you're not going to get Ebola here, saying it is a terrible problem in West Africa and we have to respond effectively there and we have to not isolate these countries or we will be at higher risk.

Q: Okay. Sound good?

49:00

FRIEDEN: It will give us a chance to think a little bit about what to circle back to for the next session.

END