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 22nd, 2016, and we are here in Atlanta, Georgia, at CDC's Roybal Campus. This is Dr. Frieden's second interview as part of the CDC Ebola Response Oral History Project. Dr. Frieden, I thought today we could start right off and talk a bit more in detail about your September 2014 Ebola report that you gave to the President after returning from your trip to West Africa.

FRIEDEN: During my trip to West Africa, the impressions were just overwhelming, but I forced myself to try to think systematically. As I traveled in the backs of cars, I was on a laptop thinking through what do we need to do, what were we seeing, what was the staging, what were the priorities, what was the approach. I was traveling with Jeremy [M.] Konyndyk, who's from the Office of Foreign Disaster Assistance of USAID, and he was a really good partner through all of 1:00that. He reflected that he was there while I was in the back of the car basically writing up the approach that we ended up following in the many months that followed. It reminded me of my time in India where for five years I traveled on the backs of jeeps everywhere and I would always write up my trip report before I left one town, before I got to the next one, so it was always done. That's kind of the way I did it here. But I then really realized this was the need, to put everything together and say clearly what's happening and what do we need to do.

I looked back on it close to a year and a half later. Unfortunately, the timeframes that were needed were just very hard to achieve. This is what I said, basically. I was clear that the world was experiencing the first Ebola epidemic ever documented; that [cases] were increasing exponentially; that the official reports were only a small proportion of the cases; that the capacity to do everything: diagnose, trace contacts, safely care for people, bury people, was 2:00falling farther and farther behind; and that we weren't reaching anything like the need that we needed to, and we needed an emergency approach with progress measured in days and weeks, not weeks, months and years. It's interesting to think back to that time. There was really a fog-of-war reality about it. It was very unclear what was going on. Early on we thought maybe there were multiple introductions from nature, so there were some, in retrospect, misguided public education about not eating bush meat, and that got almost as much attention with some of the initial stuff as safe burial. But there were people, including people from WHO who were saying oh, it's definitely gone airborne and Ebola is spreading by these airborne routes and it's going to spread inexorably. And we were kind of fighting the people saying the sky is falling. Say okay, what's 3:00really happening here? I give Stuart Nichol a lot of credit because after one of these meetings I was in Liberia and it did seem apocalyptic there. This WHO staff person was saying it's gone airborne, it's changed, it's being--multiple reintroductions from nature, it's just going to spread like crazy. I called Stuart, I was practically hyperventilating, and Stuart talked me through exactly what needed to happen and exactly what needed to be done. He was absolutely right about that, but the context was just so difficult. The weak government capacity, the mistrust of government, the mistrust of modern medical care. The vicious cycles really struck me. It was a series of vicious cycles. There were too many patients, and therefore they were cared for unsafely, and therefore more healthcare workers got sick, and therefore there was even less capacity, and therefore there were even more too many patients, [exponentially] too many 4:00patients, and it got worse and worse from that with more and more transmission.

What struck me also, what I said was basically, "The situation can still be reversed with currently available tools, but actions to date have been poorly coordinated, overly process-oriented, and haven't addressed the most urgent needs." One thing that was so counterintuitive is that planning became an obstacle to progress. Things were changing so fast. It was, "Oh, let's go make a plan!" And by even a day or a week later, if you'd made a plan it was too late. You had to act first and think later sometimes, and that was something that was very hard to get in.

I basically said we needed three core principles. First, speed is paramount. Second, we have to be flexible. And third, front lines first. It was so frustrating. On this trip I met a contact tracer in Guinea who was out there trying to do a good job stopping chains of transmission. He was supposed to be 5:00paid $4 a day. He hadn't been paid in a month. And this thing of the front lines not getting the support they needed was just infuriating through so much of this. So I said we have to reset processes for action first, and I identified ten immediate needs in five areas. Incident management, getting EOCs up, getting transport. We couldn't get people around, we couldn't get patients around, we couldn't get contact tracers around. Ultimately, the CDC Foundation got money from Paul Allen and Mark Zuckerberg and we sent hundreds of motorcycles and jeeps in to be used. They were helpful but it took months. We didn't have adequate surveillance to track what was going on and we weren't doing good contact tracing. At that point, contact tracing was impossible in Liberia and Sierra Leone. There were thousands of cases, and you couldn't do anything with 6:00the contacts anyway if they got sick because there was nowhere for them to be. You had to take it system by system. Fix the burial first, that's the least hard thing to do; scale up capacity for isolation. Then once you've broken the back of the epidemic, focus on the next phase, which was meticulous--really near perfection--contact tracing, getting treatment units up including in-country care for people, and looking at what could be done in communities. We looked at smallpox history and using huts for smallpox patients and what could be done, and many communities did something similar; burial support; healthcare strengthening; and communications, which was just horrific. So this report was a way of kind of level-setting what was happening, what were we doing, what did we need to do, and it showed how far behind we were getting and how much we needed a reset. One thing that was striking: more than 90% of the workers in the Ebola 7:00treatment units were local staff. They were folks who came forward and could be trained--were trained--by MSF. But the one thing that you had to have was an experienced site manager. They didn't even have to be doctors. But MSF had these people. They were folks who--doctors, usually but not always--could run an emergency operation with military-style precision to make sure that the bleach was mixed correctly, that every single movement was done correctly, that the logistics got managed, and that was what we needed most of. There was a guy running the USAMRIID lab at LIBR [Liberia Institute for Biomedical Research], the Liberian biomedical research facility. So the army had sent this guy there, and I thought, if we just had two hundred of him we could stop this. We wanted the DoD to be involved, but ultimately, though they did really important things, 8:00they weren't able to provide what was most needed which was that site management for the treatment centers.

Q: I want to go back quickly to something you were talking about, about the front lines first and the need for that. Was there anything that CDC was actually able to do with helping to make sure that contact tracers got paid, like somehow to advocate for them, to find funding for them to get paid?

FRIEDEN: Ultimately, down the road, we ended up giving our country directors access to $5,000 of petty cash to do things quickly and immediately. One of the more painful memories from this was at one point in the response President Obama arranged a call with the responders, our team in the field. So we had people in all three countries on the phone and he just thanked us and encouraged us, and then said, "Now I'm happy to take your questions." There were a couple of questions, and then Frank Mahoney--who is actually phenomenal, he's wonderful 9:00and he was really important to stopping both Lagos and Liberia outbreaks--Frank began a ramble. He went on, it seemed like, for fifteen minutes. It was probably only four or five minutes but it was a long time. The President tried to cut him off and stop him two, three or four times, and Frank just talked over him and kept going. And he wasn't speaking very clearly, but what he was saying was actually a very important point, was we need a way to spend a little bit of money immediately. Sometimes it's $400 to rent a meeting room today. I need cash to do that now. And of course this was offensive to OFDA because that's what they're supposed to do, but the way OFDA works is they work with large organizations, they give multimillion dollar grants, and organizations weren't coming forward to do things or weren't functional there. So this idea that you have essentially a petty cash fund and you could use that was what Frank was 10:00saying, and months later we did that through donations through the CDC Foundation. But interestingly, in Sierra Leone, the UK military had that kind of cash availability, and we had a staffer who was in an area for over two months and they said, "Nothing happened until the last week I was there. The last week I was there, the UK military rolled up and, with a brutal efficiency that had been unknown before, basically took cash on the barrelhead, paid people who were working, fired people who weren't, and things changed overnight." Of course, they could know who was working and who wasn't because our staff could tell them. But that ability was a frustrating gap all along and it almost always is. People don't want to fund jeeps and POL [petroleum, oil, and lubricants] and transport and it's challenging to get that kind of front-line-first mentality in practice.

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Q: Do you think there's some sort of structural way that moving forward we can focus on that for future outbreaks?

FRIEDEN: There are a couple of things. One, it is important to have that kind of flexible funds availability, and two, you have to fix the systems as well. So understanding how the systems work. But always there's going to be gaps and that's a really important role for transparent and honest things that are done outside of the government system.

Q: During the response, were there any organizations that refused to participate or took kind of limited participation in the incident management systems that you helped to set up?

FRIEDEN: The biggest issue for my first trip was to establish incident management in each of the three countries, and when I got there it was really chaotic. You had different government ministries in all three countries fighting 12:00to be in charge, and you had one person making a statement here, another person here, vying for the attention of each of the Presidents and competing with each other and balkanizing the response. We'll handle burial and you handle this, or we'll handle this part of the country, you handle that. So the key intervention was establishing an incident management system in each of the three countries with one incident manager in charge, and then we scaffold around that person to help them succeed.

Q: Of course, one would be reluctant to badmouth any partners at CDC, etcetera, but so many people were involved, organizations and governments, China and Cuba, etcetera. Were there issues with helping some of those partners and not just like the governments of the countries come together?

FRIEDEN: I think everyone wanted to work together, it was just a little chaotic in how to do it. That's why incident management was so important, so people knew where they could plug in. MSF called for involvement of militaries. That was 13:00unprecedented for them. We were frustrated with the French government because they really weren't stepping up with epidemiology support in Guinea and we had too few French-speaking epidemiologists, but at the end of the day they didn't have the support to send. It wasn't that they didn't want to help, it's that they didn't have it. And they ended up doing some important things. They funded the Red Cross, they funded MSF, and their military built a really impressive Ebola treatment unit for healthcare workers including traditional practitioners who got sick. It was actually the most impressive treatment unit that I saw, and I saw many, many of them throughout West Africa. They were environmentally conscious, they had video feeds, they had prayer shawls and prayer mats for the patients, they were very culturally appropriate, they had iPads for the patients to talk with their families by videoconference, they had a barracks for families to stay in while the patients were there, they had some interesting plasma extenders that were freeze-dried. They really did an excellent job at it. So it 14:00wasn't that they didn't want to, it's that they didn't really have the capacity to do it.

That's why in Guinea we put out this call for French-speaking partners because we just wouldn't get enough French-speaking staff there. Frankly, when CDC gets there, despite the good work of other partners, we pretty consistently bumped up the quality of the work that was being done. Whether it was contact tracing or infection control or training or epidemiology or surveillance or analysis or laboratory work, the quality got higher. So because we had less of a presence in Guinea, the quality of the lab work was lower. We saw false positives and false negatives and because of that we had chains of transmission including one large one because of an inaccurate test that was done. But the contact tracing quality wasn't what it needed to be. We put out this call and the Canadians came forward. They said we've never done this before but we're willing to if you'll take us under your wing, basically. And they came to Atlanta, they embedded with 15:00our teams. We oriented them. They went out in our cars, part of our teams. They became some of the leads for the response, and really today through the first quarter of 2016, four or five Public Health England or provincial public health staff from Canada have been really important to the response and they've been terrific. They're technically expert and they're fully bilingual. The second big group was the Congolese who came from DRC and they also did a terrific job.

Q: Can I ask what the initial reason was that CDC was not able to put so many people in Guinea?

FRIEDEN: We simply didn't have French speakers. It was a language problem. We didn't have enough French speakers.

Q: Through your first trip in West Africa you had that big focus of establishing the incident management systems in each of the three worst-hit countries, but I know that you traveled back a few times. What were you able to accomplish on those trips?

FRIEDEN: So I went back at the end of 2014 in December to see what was going on. 16:00I actually offered to stay and cover the country office through the Christmas break, but they said, frankly, when you're here it's more of a pain than not, so no. But basically there had been really good progress that was accelerating. We were working well with OFDA. At that point Guinea was terrifying. When I was there was the first time the Guinea ETU overflowed and they had to send patients away. That hadn't happened before and we knew there was spread. The risk was that Conakry, the capital of Guinea, would become the next Monrovia and Freetown. So we were really on the edge of another catastrophic outbreak, and when that happens, it then re-seeds the whole country because people go back to their home villages. So that was a terrifying risk there. Sierra Leone had made impressive progress, and it started this Western Area surge that was very 17:00impressive. Challenges still with laboratory work, challenges with this very misguided concept of forcibly quarantining contacts, very counterproductive, that we couldn't get reversed. Liberia clearly had the upper hand on the outbreak by that time. There were still huge needs and it was so frustrating. We still didn't have internet coverage or email coverage or phone coverage in large parts of the areas where we were responding, and that's a real complication. We had runners running with data from one place to another because you couldn't get there otherwise. And then this was the time we needed to shift to really ramp up contact tracing and follow-up and make it as close to perfection as possible where you elicit every contact, you follow them every day, you isolate them when they get sick, you make sure that if they had Ebola, you then get their contacts 18:00traced. There was poor supervision, there was poor sensitivity to the community, and the data wasn't being managed well. The contact data is very complex. Our data system didn't work for this. We had created an Epi Info system for Ebola but it just didn't work given the incredible size. Many people came in with different apps or attempts. It's too complicated to do on paper, on an [Excel] spreadsheet, because one contact might have three different index cases with different infectious periods, and then if that contact is living with somebody else who gets sick, their [time] of follow-up gets continued, and then the names are complicated. Are they actually the same people or different people? And still, we never really figured out on this kind of a scale how to manage the information. Though we tried, people worked hard at it. But it was an area where we really needed to do better.

At that point, we had begun in Liberia the RITE strategy, Rapid Isolation and 19:00Treatment of Ebola, and Frank Mahoney and Kim Lindblade and others had done that. That strategy doubled survival and cut in half the duration of outbreaks and it showed the concrete evidence for how important time was. A couple of days made a huge difference. You go from five or six or ten generations of cases with hundreds of cases to two or three generations with five or ten or maybe twenty or thirty cases. That's what rapid action allowed, and then we had to expand that RITE strategy to Guinea and to Sierra Leone.

We also realized there was chaotic collaboration. At this point everyone was moving in and doing their own thing, and it was hard to get collaboration. So that needed to be improved, and the data and the surveillance remained very problematic. Data systems were overwhelmed. There were different problems in the different countries. Liberia actually had the biggest problem. Their surveillance chief basically stopped entering data. Hans Rosling went there and 20:00he was kind of a controversial character but ultimately he helped visualize the data well. The infection control remained a huge problem. At this point where cases were ebbing, there was more and more resistance to safe burial. Liberia had gone to cremation. It was not culturally appropriate. They got away from cremation when they got a new cemetery opened. They hadn't had that cemetery opened, they were fighting over the land deed and other things. The ambassador had to go get involved. The President of Liberia had to get involved multiple times. I was really pushing on this but ultimately they got that done. In Guinea and Sierra Leone, we saw a lot of resistance to the burial teams and a lot of lack of cultural sensitivity. Subsequently, Kim Lindblade did an analysis in Guinea that showed that people were washing bodies before the burial team came, so the safe burial wasn't making it any safer, so you needed to make it more sensitive. And then we were really accelerating the point-of-care diagnostics to 21:00get a rapid diagnostic test that you could do twenty, thirty minutes at their bedside. So that was the kind of thing we were pushing by December. We had gone from breaking the back of the epidemic curve in Liberia to seeing that it was about to be broken in Sierra Leone to being worried that it was going to be on the upscale in Guinea, and we were taking steps to accelerate control in Liberia and Sierra Leone and to prevent an explosion in Guinea. That was what was happening by the end of 2014.

Q: Before we move on to 2015, I'm wondering if you can describe a bit about Martin Meltzer's model of the Liberian outbreak in 2014. What would happen if there was no intervention and what would happen if there were.

FRIEDEN: I name-requested Martin to be involved in the response over the summer of 2014 because I felt modeling was going to be crucially important. Martin came up with the model. I don't remember when his first draft was but he and I had multiple conversations after midnight on multiple days as he was finalizing it. 22:00Ultimately, that model was used internally in the US government. The kind of hockey-stick increase of what could happen with more than a million cases by January of 2015 really was pivotal to galvanizing action within the US government and within the UN [United Nations]. It got criticized because people said, oh, you're an alarmist and it didn't happen. But that's really misguided. The model showed four things. First off, it showed that cases were increasing exponentially and if we didn't change quickly, if we didn't intervene quickly, it was going to be an absolute catastrophe. Second, it showed that time was of the essence and for each month of delay the number of cases would roughly triple. Third, it showed that there was a tipping point. If we could get to 70% safe burial and 70% safe care, we could break the back of the epidemic, and that determined our strategy. And fourth, and to me most surprisingly, it showed that when we got to that 70/70, cases would decline rapidly. And that's exactly what 23:00happened. The other thing that's really striking about the model is everyone looked at what could've happened with the 1.4 million, but that same graph showed what could happen with rapid action, and that's exactly what happened. What was predicted with rapid action was virtually identical to what actually did happen with the number of cases in Liberia.

Q: Can we talk a bit about your role helping coordinate the STRIVE [Sierra Leone Trial to Introduce a Vaccine against Ebola] trial in Sierra Leone?

FRIEDEN: Let me just double back to the summer. We talked about Lagos last time but I wanted to give you one vignette of what could've happened wrong. In Lagos, the federal government initially sent a doctor, Dr. Nasidi, to be the incident manager. He's a nice man but he was completely incompetent in this role. The incident management system spent many hours discussing what to do with an 24:00embalmed body that had passed through Liberia, not related to the Ebola outbreak. Hour after hour went by. Then, how to incorporate a televangelist in their activities, then how to bring all of the media in so they could take pictures of him running the incident management system. Frank Mahoney was going to have a stroke over this. While this was happening, these hour after hour of irrelevant discussions, people who had cared for--doctors and nurses--who had cared for Patrick Sawyer were getting sick. They had nowhere to go. They were being turned away from hospitals. Other contacts were not being traced. There was no definitive action to find a place to put patients who had Ebola.

[break]

FRIEDEN: We brought the polio lead or deputy incident manager in to replace Dr. Nasidi. I had to call the Nigerian Minister of Health, said "You have to replace Nasidi." I had to call Governor Fashola of Lagos, said "This new incident 25:00manager, you have to give him all your support." Ultimately, with the new incident manager, with ten or more CDC staff, with eighty or more CDC-trained epidemiologists in Nigeria, they were able to stop it. But really, how close we were to a catastrophe can't be overstated. It really was possible at that point that Ebola would get completely out of control in Lagos, Nigeria and Africa, and if we hadn't tamped it down in West Africa, that kind of export that happened in Lagos could've happened all over, in Senegal, Cote d'Ivoire and many other countries.

Q: That's very important for people to know.

FRIEDEN: The other thing that happened over the summer that people didn't really pay attention to is that DRC had a cluster of Ebola, and it wasn't subtle. I spoke with the epidemiologists who evaluated and stopped that outbreak. A 26:00cluster of healthcare workers died in one village and then another cluster of healthcare workers died in the next village. They figured it's probably Ebola. And they went in and investigated it. They were able to stop it. They sent the CDC-trained epidemiologists, a laboratory that we've supported that was able to do it. The minister went. Apparently it was the first time people in that community had seen a car [since] the 1980s. And they were able to stop the outbreak. Basic, core public health infrastructure stopped DRC from having a large outbreak, and that's what we need to make sure every community has.

Q: And I think it's important to note with that too, as you did, that these were CDC-trained staff but who were Congolese.

FRIEDEN: Yes, the Congolese epidemiologists did a great job. They were hardworking, they were knowledgeable, they were focused, they knew the local environment, and given the information and the tools, they were able to stop it.

Q: Great.

FRIEDEN: The other thing that had happened very coincidentally in March of 2014, 27:00when the first--or maybe June--when the first Ebola cases were happening, we had a man very sick in Minnesota. We initially thought it might be Ebola. We got samples at the CDC lab and it turned out to be Lassa fever. Now, he was quite sick with Lassa, he ended up losing eyesight, and we managed his case very carefully in the hospital in Minnesota. We made sure that his urine, which contained the Lassa virus, couldn't have infected others. We made sure he got the treatment that was needed to improve his outcome. We made sure there was infection control. And everything went well with the infection control there, and that reminded us of an earlier case of Marburg virus in Colorado--

[break]

FRIEDEN: --in 2007. A woman came into a Colorado hospital with a puzzling illness, desperately ill. She almost died. She needed a gallbladder operation, 28:00she needed multiple blood transfusions, she had multiple procedures done on her, she was bleeding at the time. And all of the tests were negative. She had been--over Christmas that year, she had been in Python Cave, Uganda. Around July 4th, seven months later, she read a newspaper article about another tourist in Germany who had been in Python Cave and who had died from Marburg. She called CDC and said, "I think I might have had what he had. Can you test my blood for it again?" So we went back and had another blood test, and in fact that's exactly what she had. And we looked at that. It spreads very similarly to Ebola. And with all of that, no one had become infected. With the Minnesota Lassa case, which had just happened, no one had become infected. Even though their diagnosis wasn't made while they were ill and potentially infectious.

Q: And she had the surgery, right? Seems like an environment that would be ripe 29:00for transmission.

FRIEDEN: This is one of the things that gave us confidence--too much confidence--that contact precautions would be enough in healthcare facilities. What we hadn't counted on was the diagnosis being missed by the hospital. So the Texas patient, Thomas Duncan, coming back desperately ill, having two and a half gallons a day of diarrhea, and how intensive the nursing care was and how important it was to have rigorous attention to training, equipment, supplies, observation. So we changed the guidelines for infection control after the two nurses became infected. But we had these two cases in our minds, of this is how we had had hemorrhagic fever and Lassa, which is similar to Ebola in many ways, in the US before.

Q: One thing I wanted to ask because I've heard you mention it before but we don't have it in these interviews yet, is that at some point President Obama told you that this was like the hugest media story of his presidency or 30:00something like that.

FRIEDEN: We were sitting in the Oval Office and the President turned to me and said, "Do you know that this is the largest media story of my presidency? It's larger than the bailout, it's larger than getting bin Laden, it's larger than the superstorm." And I thought to myself, I don't have a television at home, I don't follow the news, I just work around the clock to try to stop it. At most, I scan the internet for a minute before going on to the press conferences I was doing. But it was a striking statement, and it was just an indication of how, a month before the election, what was already a great deal of society-wide concern about Ebola led to really the next level of concern and the expectation, ironically--people have such a high opinion of CDC and so much respect for CDC, they expect us to be perfect. They expect us to be able to prevent any bad outcome.

31:00

Q: So moving on, I think we had gotten to about December 2014 or January 2015. Can you describe your role getting into 2015 as the epidemic started to slow and get pretty close to zero?

FRIEDEN: Maybe I'll just go through briefly March. In March, I flew back specifically to Guinea. In the four trips I made to West Africa, it was the only one where I didn't go to all three countries, and that was because in the other two countries it was clearly on track. In Sierra Leone we had this terribly long tail that was--I'm sure, I feel confident--because of this mandatory quarantine of contacts that led to contacts not being named, led to a lot of hostility, was just the wrong way to do public health, and we were not able to reverse that policy. Even now in January of 2016, where we have another sporadic case in Sierra Leone, that same attitude is interfering with our response. So it's 32:00really a great challenge. But in Guinea, things were not on track. We didn't have enough staff, the quality wasn't good and there wasn't enough testing being done. People had to meet criteria to be tested, and we didn't know what we didn't know. There were parts of the country where there was zero testing being done. So I went back specifically to Guinea. To give them credit, they have a much harder situation than the other two countries. They are as large geographically and have as many people as the other two combined. They have more heterogeneity with more different cultural and religious groups. The infrastructure is terrible in all three of the countries but including in Guinea where you just can't get to places at different times. There was deep distrust of the government, and ironically, because they hadn't had an explosion in their capital city, there was still the sense that Ebola isn't real, you're just making this up to steal money from the foreigners. And this was a widespread 33:00perception. In fact, the President of Guinea, with whom I've spent many, many hours, was furious about it because he needed to say, "Look, I'm not getting rich off this," and yet he was getting attacked for "You're just making this up." The US Ambassador to Guinea pointed out to me that Ebola was the 17th-leading cause of death in Guinea. It was not one of their major health problems, so people weren't taking it so seriously. Even hospitals where multiple healthcare workers had gotten Ebola and died weren't doing reliable infection control. So Guinea wasn't on track, and too many patients were only being diagnosed after they had died and been unsafely buried.

So basically what I focused on there was we have to up the game in terms of quality. Every single case, every single cluster needs a response that's as close to perfect as possible, and the Congolese and the French and our epidemiologists there and then WHO had some better staff there who were more 34:00competent, they were able to up the game in terms of the quality of contract tracing. Second, the testing of patients and decedents had to increase. The testing was at a tiny level compared to the other two countries, and we ultimately were able to get rapid testing up and running there. That took longer than it should have because there were barriers to it. We finally got that up and running when I went back to DRC--went to DRC--to thank them and meet with my staff there. And I met a CDC laboratory expert, Nadine Abiola, who just gave a presentation on what she was doing in DRC, and I said, "How about going to Guinea?" So, if you speak French, you couldn't get too close to me or you're going to get sent to Guinea. And she went to Guinea and she was pivotal in getting the rapid diagnostic test set up, but it took a long time to get that done. There were other, more accessible testing methods like the gene expert that were also being scaled up. But we didn't have a lab in Guinea and that made 35:00scale-up of testing [difficult.]

Second, they needed to improve the interactions with the community. There were still frictions and you could tell them. At one point, a woman had gone in as part of a burial team and it was a man who had died. I can understand how this happened--it's roasting hot, she's in full PPE [personal protective equipment], and after they put the body in the back of the van, she takes off her PPE and she's wearing a tank top. This is a Muslim community, and there was violence. So we had multiple episodes of violence in Guinea and some of it was because of longstanding hostilities and some of it was triggered by a lack of cultural sensitivity. The Guinean Red Cross had sent her and others out and had not had much cultural sensitivity. So the divisions in society that previously had been there were just exacerbated by Ebola. That point about getting to zero in Guinea 36:00was that it didn't require a different strategy. It just required getting the details of the strategy right consistently with EOCs and testing and community engagement, and that was critically important.

That reminds me to mention that in my first trip to Guinea, I had met Dr. [Zabulon] Yoti from WHO. He's one of the world's top Ebola experts. He's really good, and what he said to me made a huge impression on me. It emphasizes that though WHO gets a lot of criticism for their response--it's merited in many cases--they also have wonderful technical staff, and we need to strengthen those technical staff and support them. Dr. Yoti, Zabulon, said to me, quote, "The same things that have controlled every Ebola outbreak can work if we scale up." That was really the essential message and that's what we needed to do in Guinea because it was clear that we were a long way from zero. They were lagging far 37:00behind the other two countries.

Finally, I went back over the summer in August and September of 2015. It was clear that Liberia was having impressive progress. It was also encouraging that they had done a bed net distribution and a measles vaccination campaign that had gone well. Those are two things that are really important. You want to build on Ebola. You don't want to just eliminate Ebola, you want to eliminate Ebola and strengthen the whole healthcare system so that not only does Ebola not happen again, but these are some of the sickest countries in the world and you can really make a lot of progress through the interventions there.

So Liberia was definitely on track, Sierra Leone was continuing to have both remarkable progress but still challenged with the transition plan because they had been so military-dependent. It was not clear at all how they were going to transition to the Ministry of Health, which had been, frankly, corrupt and incompetent before, and so it was removed from them. In fact, the incident 38:00manager Paolo Conte said to me, "When the Ebola epidemic is over the EOC will disappear into thin air." And I was like, well, that's actually not what we hope will happen because whether it's Ebola or other things, we need Sierra Leone to be ready. Actually, the EOC has stepped up, the Ministry has stepped up as we sit here in January of 2016 and is running an EOC reasonably well. It could be better but it's functional. Again, the challenge with this quarantine was making it harder, and by this time it was clear that sexual transmission was going to be a lingering problem, that we might have sporadic cases for many months into the future. So we were setting up semen testing programs, and I saw the program that had been set up in Sierra Leone, and that became a model for the other countries to set up a sensitive program. It turned out that this was highly desired by the male survivors. They wanted to know. So it wasn't something that needed very aggressive marketing. They wanted to know if they're positive or 39:00negative and that's something that goes on to this day.

In Guinea, there was excellent progress, but such challenges with survivors. Through all of this, the challenge of dealing with survivors has been so frustrating. The first time I went, I suggested that we set the policy that we will offer any survivor a job because we want them to have economic support, we want them to be part of the response, and we want to de-stigmatize. That just never happened. In Guinea, where there were survivor associations, it just took a year to get them support. As I look back to my initial report, I said, this has to be done in two weeks, this has to be a month, and it ended up being done in six months or a year or a year and a half. Survivors [are] very important because by not treating the survivors as VIPs, we ended up making it more difficult to stop the outbreak.

Q: Do you have any personal recollections of personal meetings that you had with 40:00survivors that kind of stick out?

FRIEDEN: There's a nurse in Guinea who is a survivor, and she was very ill. She was infected at the hospital, and when she got better, they wouldn't let her come back to work. She had so much stigma, even from healthcare workers who understood Ebola, that she couldn't work there, she couldn't live in her home, she had to move to a different place. But she's still focused at trying to improve things. Also in Guinea I met three people who had been medical students or doctors in training who had gotten Ebola in March of 2014 before it was recognized. They had survived. They were part of the initial cluster, and to meet them and hear their stories and recognize that these are the people for whom it all started and they might've died, they were just taking care of 41:00patients as medical students. One of them was very organized and proposing to run a survivor network, so it was very encouraging. I also spoke with a woman in Sierra Leone who talked about how devastating it was to be a survivor. Her husband had died and she had terrible problems. She wasn't allowed to go to the well or the pump in her village because people were afraid. Shopkeepers wouldn't sell her anything, wouldn't touch the money she had touched. So terrible stigma against survivors. I met with a number of survivor groups. We tried to get the presidents of each of the countries to embrace, physically embrace, survivors. President Obama embraced a survivor at the White House. This was very, very important, but a very challenging area, and for the long term the survivors will face stigma, and the fact that they can in fact spread Ebola through semen and potentially other means makes that even more challenging to address.

Q: It looks like potentially some survivors might have issues with eyesight and 42:00some other issues. I know that CDC has long-term offices now in the three worst-hit countries. Is that something that they might be able to focus on?

FRIEDEN: We're working on scaling up services for survivors. Certainly, eye symptoms are a major problem. We've supported a couple of non-governmental organizations to do treatment. I insisted on giving money to the military hospital because they've got hundreds of survivors in their clinic and they're providing some treatment. I don't think it's been fast enough. In fact, I don't think anything in the Ebola response has been fast enough, but it is coming into play and it just shows how important speed is. What I emphasize to people over and over again in terms of speed is an adequate action today is worth way more than a good action in a week or two weeks or a month. That old saying, don't let the perfect be the enemy of the good. Our mantra here was don't let the good be the enemy of the adequate because we just needed to get stuff done and to trust 43:00communities, to build on the strength of communities to do more.

Q: Can we go back for a minute and talk about the STRIVE vaccine trial? For the record, the Sierra Leone Trial to Introduce a Vaccine Against Ebola.

FRIEDEN: Early on we thought, you know, there's a vaccine that's pretty promising. The top experts at CDC said to me, we would take it. There was a question of is there enough, where is it, how do we get it there, what are the transport needs, and then how do we do studies on it. In the internal debates on this, both I and Frank Mahoney wanted to do ring vaccination trials, but the vaccine program felt that it would be better to do a phased healthcare worker trial. So that's what we did in Sierra Leone. I said, you can do that but please don't interfere with the response. It has to be a separate team so the vaccine team and the response team are separate and you're not interfering with the work of improving contact tracing and epidemiology and infection control and all those other things. And they did a terrific job. We had over one hundred thirty 44:00people work on the STRIVE trial. It was a massive undertaking. They vaccinated over eight thousand people. They had over 90% follow-up rate. They have the largest trial that has been done. They'll have immunogenicity data from West Africa that will be very important in licensure. It's a real success. The disease control team beat the vaccine team in terms of speed, so there wasn't enough Ebola around to see if there might be a productive efficacy. Meanwhile, WHO and the Norwegians and a European consortium did a ring trial in Guinea. By fortunate happenstance, the places they did it were the places where there was some transmission, and they've been able to show good efficacy of the vaccine.

Q: I have one last question before I just ask you if there's anything else you'd like to have for the record. How did the Ebola epidemic change how you were able 45:00to implement the Global Health Security Agenda?

FRIEDEN: Well, first and foremost, because of Ebola we got about a billion dollars for global health security and Ebola. That money is desperately needed to implement core programs to protect these countries and the US. Without Ebola, we wouldn't have that money and we wouldn't be changing the world in terms of preparedness. Also, although we had spoken about Ebola when we launched the Global Health Security Agenda, when Ebola hit--I've been saying for years we're all connected. It made it very clear that we're all connected.

Q: Is there anything else that you would like to have on the historical record about Ebola?

FRIEDEN: There were a few lessons from the H1N1 pandemic that pulled through to Ebola. One of them was that the White House wanted us to basically federalize 46:00the response, to run the vaccination program for the whole country, and they just couldn't accept the fact that in the US, health is a state affair and we function and we implement by helping states and local governments do a better job. And in H1N1, that meant that we embedded with states, we funded states, we did stuff with states, but we didn't do it ourselves directly. The same dynamic played out with Ebola, where there was a desire to federalize the response and yet that's easier said than done. We don't have the legal authority to do it. Across the US government, we don't necessarily have the capacity to do it. And perhaps most importantly, we're not optimally situated to do it. So in Dallas, when they needed to find an alternative residence for the family of Mr. Duncan, the local staff could do that. We wouldn't have been able to do that. And that 47:00dynamic of the need to work through state and local partners even if they're not optimally strong played out in both of those health threats.

The other thing that played out in both is: what works best in an emergency is scaling up regular systems. So in H1N1 we really did a great job of getting the vaccine out as soon as it was available. Now BARDA [Biomedical Research and Development Authority] overpromised in terms of when it would become available, months earlier than it actually did, and how much. But the moment it rolled off the production line, we were able to get it out into doctors' offices and people's arms. In contrast, getting antiviral medication Tamiflu out was much harder. The reason for that was that we got the vaccine out through the Vaccines for Children program. We had an infrastructure. We were able to do more than three hundred thousand deliveries to more than seventy thousand points--doctors' offices and other clinics and places--without a glitch. In contrast, with 48:00Tamiflu, we shipped it out to the states and they didn't really know what to do with it, so it was underutilized in the H1N1 pandemic. The challenge of Ebola was that there was nothing like it. We didn't have any other disease that caused this type of problem that people could learn from. If it came to contact tracing, yes, we knew that from TB and STD [sexually transmitted diseases], but in terms of the infection control in hospitals, that had to be really created from scratch.

Q: I think that the message that we can't often immediately federalize the system, that CDC cannot take over, was also kind of problematic in the media--that people assumed that CDC was going to parachute in and take over the role of local health departments.

FRIEDEN: Yeah. Early on in the Dallas response I had a phone call with Judge Jenkins, and he said, "Who's in charge here?" And I said, "You are, Judge. It's 49:00the local area. We're not federalizing this." I was at a panel a month or so ago with Ron Klain, and Ron said, "People shouldn't be afraid that the federal government is going to come in in black helicopters and take this over; they should be afraid that the federal government doesn't have the ability to do that." That may be the case, and we need to think about what we can do to surge in, but fundamentally we need a stronger public health system throughout the country.

[break]

FRIEDEN: When I think about Ebola, I think about what should have been, what could have been, and what will be. What should have been is no epidemic. If there had been core public health systems in these three countries, it would have stopped, just as DRC and Uganda and other countries have stopped hemorrhagic fevers in the past. What could have been is way worse than what was. Without the rapid action in Lagos, without tamping it down in West Africa, we 50:00could truly have had a global catastrophe where Ebola spread throughout Nigeria, throughout Africa, not just for weeks but for months and years, and killed people not just from Ebola but also from all of the things that we can't care for when there's Ebola, whether it's vaccines or AIDS [Acquired Immune Deficiency Syndrome], TB, malaria, or maternal health issues. It would have changed how we do healthcare all over the world. If you had to consider every traveler from anywhere that might have Ebola, any time they have a fever that they might have Ebola, it makes it almost impossible to respond. So avoiding that global catastrophe is what could have been. What could have been is much worse than what was. What will be, I'm hopeful, is a much stronger country, a much stronger world where we're able to detect health threats quickly after they emerge, respond rapidly, and prevent further spread wherever possible. A safer 51:00United States and a safer world.

Q: Thank you very much, Dr. Frieden.

FRIEDEN: Thank you.

END