Abigail Carlson

Q: Today is Friday, February 18, 2022. This is Mary Hilpertshauser for the COVID-19 Oral History and Memory Archive Project. I am in Atlanta, Georgia, and I'll be talking to Dr. Abigail Carlson, who is in Decatur, Georgia, and we're recording through Zoom. Do I have your permission to interview you and record this session?

CARLSON: Yes.

Q: Thank you! For the record, can I ask you to just say my name is, and then state your full name.

CARLSON: Sure. My name is Abigail Carlson.

Q: Good. Dr. Abigail Carlson received her bachelor's degree from Wellesley College, and her medical doctorate and master's in public health from Johns Hopkins University. She completed her internal medicine residency at McGill University Health Center in Montreal, Canada, and her fellowship in infectious diseases at Washington University in St. Louis/Barnes Jewish Hospital. Dr. Carlson was an assistant professor of medicine at Washington University in St. 00:01:00Louis, serving as a clinical infectious disease physician, and associate healthcare epidemiologist at the Veterans Affairs St. Louis Health Care System. Dr. Carlson is in the Division of Healthcare Quality Promotion in the National Center of Emerging Zoonotic Infectious Diseases, at the Centers for Disease Control and Prevention. During CDC's pandemic response, Dr. Carlson serves as subject matter advisor on healthcare epidemiology, infection control for CDC's Project Firstline. Dr. Carlson, welcome to the project, may I call you Abby?

CARLSON: Yes, of course.

Q: Okay, I am talking to Abby about her COVID-19 experiences. But before we delve into those details of your path to CDC and COVID-19, could you tell me a little bit about your family background and the community where you grew up?

CARLSON: Yes, so I was born in Rochester, Minnesota, my father at the time was actually a resident in internal medicine at the Mayo Clinic. But he finished 00:02:00very quickly after I was born, and we moved up to Northern Minnesota, so I spent my early years in Northern Minnesota, where he practiced medicine, and then Mother, who's a musician, ended up being a homemaker, and I have two other siblings that were born after me, I have a younger sister, and a younger brother. We lived up there for about eight years, my father practiced there, and then got an offer to go back to the Mayo Clinic. He moved us down, we moved down with him back to Rochester when I was about eight years old, and I otherwise grew up in Rochester, and lived there until I was seventeen, when I started going out in the world for education, so that's kind of my childhood background.

Q: Okay, can you tell me a little bit about your Wellesley College experience and your interest in medicine?

CARLSON: Yes, so at Wellesley, Wellesley was just a wonderful place for me. It was a great four-year experience. It was interesting, 9/11 was a week after I started college, two weeks after. That was really, that colored my college experience, and I was an international relations major, so that made it even more kind of pertinent to what was going on. You know, how I got there from medicine, during college I really struggled a lot with whether or not I wanted to go into medicine, or something else. I very distinctly remember a conversation with my father, I had been working at Mayo one summer and was on the evening shift in sterile processing, so I would work from 3:30 to 11:00, and would rarely see my dad, so he and I would have lunch on occasion.

We were having lunch, and we had gone on a walk after lunch, and talking about what I wanted to do, and he said, you know, I've always encouraged you to go into medicine because I know you can do anything you want with the degree. That was really the moment that I was like, okay, I'm going to go into medicine. I might major in international relations, but I want to do international relations, international work in the context of medicine. That was sort of, that was my college idea at the time, not knowing anything about public health, or you know, healthcare epidemiology or anything, but that's how I got into medicine during college was through those conversations with my dad.

Q: Oh, that's wonderful. His--did he inspired you into a medical career?

CARLSON: Yes, yes! He did, you know, going back to Park Rapids, Minnesota, Northern Minnesota, when I was little, when we were young, again he was working really, really long hours, and so we would go into the hospital with him on 00:05:00rounds on Saturday mornings, and we would sit in the doctor's lounge while he would go on rounds, and that was how we got time together.

But you know, for a child of four years old or three years old, the doctor's lounge meant everybody's attention, color Sesame Street on television, and unlimited pop and cookies. Medicine was this thing where oh, Dad goes into the hospital and saves people, and you get pop and cookies on the side. [laughs] For sure there was always this impression of like, this is something that I could want to do, it's helping people, it's going out in the world and doing something of value, and I admire what my father does. You know, I enjoyed the sciences, and found them intriguing, I found the body intriguing and wanted to kind of take that road further. I kind of followed these parallel paths of being very interested in social sciences, economics, political science, history, and then 00:06:00being very interested in biological sciences and ended up here. But yes.

Q: You mentioned that 9/11 happened two weeks after you started at Wellesley?

CARLSON: Yes.

Q: Did that inspire, not inspire, that's a bad word for it, but did that move your judgment towards something in public health? Or, because you're--

CARLSON: You know--

Q: --you're in medicine, you were all about medicine, your dad is in medicine, and then--

CARLSON: Yes.

Q: --you have this, and you're teaching medicine sort of--I'm kind of jumping over here. There's a lot of things that may have pushed, not pushed, but inspired you, a bad word too, I can't think of the right word, but I will when we get to the transcripts.

CARLSON: Yes no, affected it, it--

Q: Yes, there we go!

CARLSON: Yes. There were a lot of forces, I wouldn't say that, you know, what 9/11 did is it really, it totally changed kind of how you saw sort of the future 00:07:00of the world. This was an era where globalization was just coming to be sort of this thing that people were very aware of, and had concerns about, and so, and climate change is just starting to be kind of on this radar, and so I'm, you know, an eighteen-year-old in an environment where I'm studying these things all the time, and so they are, they're influencing how you're reimagining the world, and of course, this was only, not even ten years after--well no, just about ten years after the Soviet Union had fallen. All of these things were happening on the world stage, and then 9/11 happened. It just, it totally changes, you know, the flow of things, and the community.

The community grows in like, at Wellesley, our class grew very close very 00:08:00quickly, especially the women I was living with in our dorm, because our dorm was only like thirty people. We all spent that entire day watching the news together in the common room. You know, and we'd only known each other for two weeks and then all of a sudden, we're experiencing this huge event. I think that what came out of that though was this sense of, there was a sense of service to community that was underneath everything, even though, you know, I wouldn't say like oh, 9/11 pushed me towards public health, I think in your mindset at that time, there was very much a sense of coming together, and what can I do for people, and how do I, you know, how do I do good in this world that is very much 00:09:00in the middle of upheaval?

Which I wonder what college students during the pandemic are thinking, because I can imagine that in some ways some of the same emotions are there in a very different context. I would say it didn't necessarily push me towards public health, but it colored everything that kind of came in those next four years, because it was the topic of discussion for at least the first year of college, it was just omnipresent.

Q: Oh yeah, yeah. Now you served as assistant professor of medicine at Washington University in St. Louis.

CARLSON: Yes. Yes.

Q: What were the years there, when were you there?

CARLSON: I was there, so I did my fellowship training there starting in 2013? Yes, 2013 to 2016. Then I started as an instructor in 2016, got promoted 00:10:00somewhere in there, I think like 2019, and was there until September 2020, when I joined the CDC.

Q: Okay. You were there when you first heard about COVID-19?

CARLSON: Oh yes. Yes.

Q: Okay, so let's move on to that then.

CARLSON: Yes.

Q: When you first heard about it, you were still in a hospital situation? You had patients?

CARLSON: Yes. I was the associate healthcare epidemiologist [Veterans Affairs St. Louis Health Care System], and I was the chair of the infection control committee at the time. Sort of, my boss was the chief hospital epidemiologist, but he basically was letting me run the show of things, and you know, as an infectious diseases physician, you kind of keep your ear out for the things that are popping up, and there will regularly be news stories about, you know, oh 00:11:00there's an unusual case of this here, oh there's an outbreak of this here, but you just, you know, you keep your eye on and say hmm, that's interesting what's going on. You usually don't think much of it because most of the time, within a couple of days, they will have determined what's going on, and it will be like okay, this is something we know. Or okay, this is something that's not contagious, it's not coming this way.

I actually-- remember hearing about-- I don't remember the exact context, I definitely remember reading the news within the first week of January and being like oh, a new pneumonia in China, that's interesting, and thinking hmm, it could just be nothing, it could be oh, this is an outbreak of something that we know about, or not. It was very quickly apparent in the following weeks that the answer was this was something new, so yes.

Q: Yes, so your role was the hospital epidemiologist when the pandemic began.

CARLSON: Yes.

Q: Okay. When you say "they", they will have determined, who's they?

CARLSON: Oh, you mean like they will have--so it really depends, usually it's a public health or medical group in a country, wherever an outbreak of something is happening, a group will say oh yes, no, this is Crimean-Congo hemorrhagic fever, this is, we've determined it's pneumococcal pneumonia, we've determined it's, you know, related to X, Y, or Z. It's usually a local thing. In this case [SARS-CoV-2], it was local, and it was also international. I think it was one of the things that was sort of determined in combination between China and the WHO [World Health Organization], and I honestly don't know exactly how that all went 00:13:00down, I forget the exact timelines. But by February, so once we knew that this was something new, we as the healthcare epidemiology team, so the infection preventionists who were all nurses in my hospital, and myself, and our, my boss, our chief hospital epidemiologist, we were starting to say okay, well what do we need to do, what do we need to prepare?

You know, by the end of January, it was pretty clear, it was not for sure, we still weren't sure whether this was going to become global or if this was going to remain, you know, just a localized thing, but we started to say okay, if it's going to go global, and there's a real possibility it will, you know, what are the things we need to do? I remember sitting in my office, in fact, I still have 00:14:00this, I have these big white post-it note like, easel-sized sheets, and I put it on the wall and with a Crayola marker just started listing the things that needed to happen. By February third, I was giving a presentation to our medical executive board and saying okay, you know, there's a real possibility this could come within the next two to three weeks, it turned out to be a little longer than that, it was more like five. But if and when it comes, here's what we need, and we need, you know, you need to think about where we're going to put negative pressure, you need to think about having N95s, which by February third, it was too late.

Nobody had N95s, we didn't know that. But you know, we need to think about our PPE [personal protective equipment] supplies, we need to think about this, this, this. Just, you know, put a huge list of things together and presented that. Then it was kind of slow for a month.

Because it wasn't in Missouri, even the first case, of course, was on the West Coast, and then it wasn't entirely clear that it was circulating in the United States for a couple weeks more. But around the beginning of March, I think it was like March third, fourth, fifth, right around there is when we finally said, you know what? This is, we need to set up incident command, it's in the United States, it's circulating in the United States, it's only a matter of time before it gets to Missouri, we need to be ready. At that point, it was like everything exploded, at least on a personal level of the personal life. I think the rest of the world kind of went on for about one more week before everything shut down, but for us, like that first week of March it was the time where just all chaos broke loose.

Q: What was it like to be part of that incident command team, and was it--yes, 00:16:00start with that.

CARLSON: Yes. I was, it was tough. I mean, it was tough. I think it was tough for anybody who's involved in an incident command, particularly in emergency like this. These are really designed to be put together for a couple of weeks and then stood down. They're meant for short duration emergencies. They've been used to long duration emergencies, in fact during medical school I was actually part of the H1N1 response at Johns Hopkins, and so we, I remember incident command, I had participated kind of on the sidelines as the person who can make PDFs, that's a long story. But I was a med student, I was in the end of my fourth year of medical school at the time. You know, we stood it up for two weeks, and then they kind of backed down and it went back into hospital integration. That is not what happened here. But the initial push is one that 00:17:00is, the logistics are just absolutely astronomical.

Q: Can you explain those logistics? Because I don't think a lot of people know what it's like to be in there.

CARLSON: Yes. Yes. You have, in an incident command, and I am going to butcher this, because the details are complex. But essentially you have one person who designated the incident commander, so that person is like, in charge now. For our situation, it was the medical director, so really, the chain of command in that sense didn't change. But then you have teams. You have, so I think we had operations, finance, we had, I think we had a separate logistics team, separate from operations. We had a team that was mostly myself and my boss, and you know, sort of the, a few members of leadership deciding kind of clinically what we 00:18:00needed to do. I think we titled it the strategy team. But essentially, a group of people who decides what needs to get done, a group of people who makes it happen, a group of people who figures out how we're going to pay for it, a group of people who figures out how we're going to get the supplies to do it.

Then of course all of that is running through, this is the VA [Veterans Affairs], so there's a national team that you are kind of associated with, kind of, even though there's a lot of independence in VA hospitals for things like this. But it was the kind of thing where, you know, we had to think about how are we going to screen people, right? We have, I can't even remember how many buildings we have, but we've got at least seven to ten outlying clinics with, you know, buildings that we rent versus buildings that we own, the hospital was built in 1952, and then there was two sites, John Cochran in the center of the city, and Jefferson Barracks south of the city.

You've got long-term care, you've got acute care, you have ICUs [Intensive Care 00:19:00Units], and you have to figure out how all of those are going to run in the context of a pandemic. Who's going to staff units? Where are patients going to go? How are they going to get there? How are you going to identify that the patients are ill? Then, you know, with the recommendation of N95s, and this was, OSHA [Occupational Safety and Health Administration] had not, so OSHA had not yet said that you could suspend fit testing. Fit testing is this process where it takes about seven to ten minutes, it's designed from 1972 or '74, it's not even designed for N95s, which didn't exist at that time. But it's designed to make sure they fit, which is important, right? You want to protect workers. But that process is very long, it's time-intensive, and we've literally had two 00:20:00people on staff who could do it.

We had a staff of four thousand, and most of them were not fitted for an N95. Because other than the pandemic, you know, you use it for chicken pox, measles, and tuberculosis or Ebola preparation, so there was a team that had gone through Ebola preparation in 2014 who had it. You have to figure out how are all of these people going to be fitted for N95s, and by the way, we don't have any, right? February was too late, we had, I think, gosh, I don't even remember the numbers, I remember though, I remember one weekend, one Friday early on, being told with our current mask use, we have enough masks to get through about forty-eight hours. Yes. Like, and then there wouldn't be any. It's not like there would be other options, or the shipments are delayed, there weren't any. 00:21:00Like there was none.

Q: What happened? What did you do? How did you deal with that?

CARLSON: It became a question of, okay, who gets to wear a mask, right? In what situations are you going to wear a mask, in what situations are you going to wear a respirator, who's going to do it? The easiest way to do it is to put the patients in sort of the same local area. For patients who are going to need, who are going to pose a risk, so patients who have symptoms that are like COVID-19, who meet the criteria for being tested for COVID-19, which by the way, we also didn't have testing, so that is a whole other thing. You say, instead of them going to all of the seven or ten, you know, however many outpatient clinics, they're going to come to one place, right? But that puts a huge burden on that 00:22:00one place, and that one place ended up being the main hospital, and in fact I think we had to set up one other place, because it was just too far for some people.

I mean veterans, particularly those who remain in the VA system, are not wealthy folks, and transport is a big deal. We had to figure that out. Same on the wards, what you do is you say okay, you know, if you need an N95, you have to go through these steps, you have to go through these processes. Which means logistics has to be involved to say we will supply N95s here. Nursing, and physicians, and all who are going into tuberculosis rule-out, which is still a thing, and there's always a patient or two who is in it, still need to be able to access those, and those patients should not be with COVID patients, right? 00:23:00You have to, that logistics ended up being, what ended up happening, logistics went through the hospital over a weekend, and room to room, and if they saw a box of N95s, it was taken away. It all got centralized into one place, and there's pluses and minuses to that, so people had to, people who truly needed them had to go back and request them. But it really became a, you know, it became a, I've only got enough to get us through to a few days, and if you don't need a mask, don't use it. You know, for the most part people were okay with that. This was also, people were starting to find N95s, KN95s sort of on the street, as it were. Quite literally sometimes!

They would bring it in. I remember, I mean to just give a sense of the absurdity 00:24:00of this, my boss, one of his neighbors traded toilet paper for some construction N95s that somebody had had. His neighbor then gave those to us, the infectious diseases department. I mean we were like, this is absurd, and then we locked it in a drawer, because we were like, we might need them. You know, I was--my sister is an architect, so I was calling her being like, okay, if I need to use a filter to make a mask, to make an N95 or something close, what kind of material can I use? Can you think of things in construction that I could use? There was this whole discussion of well, you can't use these because they're made of fiberglass, you don't want to breathe those in, you should use--so you know, we'd had those conversations. One of our surgeons, we actually had a sewing circle. One of our surgeons realized that the filtration of some of the 00:25:00anesthesia cloth, that we had a large supply of, was very good, it was close to ninety, ninety-five percent.

I don't know if it was, you know, tested, and he said, "I think we can make masks out of this." He made a design and kind of prototyped a few and did that, and we ended up sewing a bunch of those out of this anesthesia cloth that actually, people really liked. But I mean can you just imagine, people who would otherwise have other jobs, we were pulling them off their jobs and saying, you can sew? All right, we've got, you know, a very socially distanced room where you can sew these things, here's the cloth, here's how we're going to do this. There was a lot of, like, there was a lot of issues around transparency, and sort of a lot of struggle within the leadership about just how transparent to be with people. But I am, my tendency is to be very straightforward, for better or worse, and so it was one of those things where I, you know, the staff, the 00:26:00medical staff, the physicians were like why are we not universally masking?

I don't understand why, you know, you aren't recommending universal masking, which by the time, at that time it wasn't clear that it was important. The initial studies that have been done in influenza, way back, you know, in the decade previous, had suggested that it didn't work, and that's why there was some hesitance, I think people think that oh, you know, we, the CDC [Centers for Disease Control and Prevention] didn't recommend it early enough, which may or may not be the case, but frankly, from the ground level, I wasn't recommending it because the data was bad, and we knew that the data was bad. It was only kind of a couple of weeks in that we started to get data that suggested otherwise.

At that time, there were no masks, again. There were no masks, so not even for 00:27:00the hospitals, so why would I go tell a community to take medical masks when I can't even get masks for people who are treating--influenza, by the way, was still going on at the time, we still had flu patients at the very beginning, so they were treating flu and I'm, you know, I can't tell a nurse to go into an influenza room unmasked, right? I just, that's morally, incredibly fraught. Not to mention like, just nothing legal about it, the ethics of asking somebody to put themselves in danger like that is tough. I wasn't about to say we could mask, and so I had to just go to the physicians and say, look, I, you know, it's not a bad thing to do, it's not like it has a lot of consequences for everybody to wear a mask, except I have none.

I think once they were confronted with kind of the numbers we were looking at, it became a little bit easier. But there was just, it was chaos all around, 00:28:00people were bringing in masks, I'm sure the hospital spent six to seven figure sums on counterfeit.

Q: Sure.

CARLSON: Because you know, logistics didn't know the difference, and neither did I, and there's still, you know, two years in, not great ways to identify counterfeits. There was chaos, we were working twenty-four/seven, we had a phone line that was open to infectious diseases twenty-four/seven.

That, you know, my boss and I made the agreement that we would get one day off a week, each of us, and we'd flip it between the two of us and then my best friend was also, is our other kind of full-time colleague, or near full-time colleague, and she ended up taking it, she was pregnant, that was a whole different thing, her obstetrician was like, you need to get out of there. We said okay, you know, it's just Jay and I then. She would do the phone, but she could only do it four days a week, because it was constant, she wouldn't get any sleep. We would take 00:29:00the weekend. Anyway, chaos. In the meanwhile, it just kind of felt like a perpetual Sunday afternoon, right? You would drive to work and there would be nobody on the roads.

You'd get to work, and things would seem mostly normal. I mean it was quieter than usual, but things would seem mostly normal. You know, I still was on service, I was very foolish, tried to do medicine service like the second week of March, and that was unsustainable, my boss by the end of the week was just like you can't, we're finding somebody else to take over for you.

Q: Describe, what is medicine service?

CARLSON: Medicine service is when you are the attending for an internal medicine team. The team is of residents and students, and you're taking care of inpatients. In this case, it was non-COVID patients, all the COVID patients were being routed to a unit that we had set up.

But the, it essentially is you round on those patients once in the morning, and then you're there for the students and residents as they need things during the day, and then you kind of do a second sit down rounds in the afternoon. It was just chaos, the patients still need to be taken care of, right? They all, day in and day out, stuff was still going on, and meanwhile, everybody's, you know, calling me, what do we do about this, what are we, you know, we need a rule for this, this isn't working. You know, dealing with that. Trying to balance that phone which was going off constantly with being there for the medicine team, I had a wonderful team of trainees, but they're trainees, right?

Q: Right.

CARLSON: You have to be there. It was, you couldn't do both. I mean maybe somebody more skilled than I could, but I certainly couldn't. At the end of that 00:31:00I was like nope, I have to hand the team off to Catherine McCarthy, who took over for me, so. Everybody was really, all of my sort of colleagues and friends were really wonderful about that time. You know, they'd pop in and they'd have, they'd say you want lunch, we're ordering lunch, or they'd pop in with snacks. I literally told my mother, I need, I couldn't get to the grocery store, I couldn't go, like I just didn't have time. I said I need you to send things that I can eat out of my pocket. That's what she did, she just sent a bunch of like, a bag of almonds, and prunes that I could stick in the cupboard at work, and a bunch of Kind bars that are, you know, these nut bars, that I could stick in my pockets in my coat, and that's what I did. I literally carried food, because you know, you weren't going to sit down. You weren't going to sit down to eat.

Q: I'm going to ask, was there a feeling of fear in the air? Was there a feeling 00:32:00of, where is the guidance on this?

CARLSON: You know, I think that at least on the physician side, right, there was, it wasn't that there wasn't fear, there were some people who were terrified, particularly people who had family in China, who knew what was going on in Wuhan and were like, holy smokes, you know, this is a disaster, right? They were very vocal that we weren't doing enough. I think that there were also people on the flipside who were like, you know, is this just, are we overblowing this? But not a lot, honestly. Quite honestly, most people are like okay, you know, this is what we need to do. There were a number of people who would have 00:33:00met criteria for not working with COVID patients, and for being sort of, not put on administrative leave, but essentially tasked out away from clinical work, and particularly amongst the physicians, there was this, this is my calling, this is what I am meant to do, you cannot tell me that I can't see patients just because of my X, Y, or Z.

I think for that, it was just like okay, yes, no I'll take your staff because I need you. As long as you're willing to work, yes. I think there were just, there's a wide range of reactions, from holy smokes I'm not seeing patients, and you know, from somebody who's very, very low risk, to a high-risk person saying this is my duty, I am dutybound to respond to this pandemic, and a lot in between. Just a lot of questions, and so you know, for on the physician end, 00:34:00because that was more my responsibility to manage, and sort of leadership was managing the rest of the staff, I started doing a once a week, or once every couple of week webinars. It was hard to fit them in, to be honest, just because of scheduling, but I would try to sit down, and we were doing this, now we did it on WebEx at the time, which people were not familiar with doing these things by WebEx or Skype. It was a brand-new world for a lot of people.

We would sit down, and I would have, you know, two hundred staff logging in, and I would say here's the updates, and then launch a Q&A. Then we did a few town halls for the full staff where I was able to do that with the full staff, and they would ask. There was a lot of, you know, a lot of sitting down and letting people ask the questions, that was I think very, very helpful for managing things.

That isn't to say that it was easy. Like there was definitely a feeling, you know, there were colleagues that would attack you, and there, you know, it was out of fear, or frustration, or anger, and that totally, it makes sense, but it is also very difficult to be in this thing where, in this space and time where you are responding to a pandemic, and also, you know, and trying to make that happen, and also kind of fending the attacks from within, from your own, right? There's a certain loneliness to it. That being said, I wasn't the only one.

I remember, there were a number of people from the dental clinic, which had been shut down at that time, who had ended up doing screening, and they would get 00:36:00attacked by their colleagues, you know, the ones who didn't think that they had to be screened, or people who thought that they were screening wrong, or that--and I just remember sitting in the basement with them, you know, because I had gone to help answer questions for them, and they were telling me this, and I'm like yes, it's really, really hard, and you know, all of us just kind of sat there and were like, we're in it together, and this really, really is, it sucks.

Q: Sorry--

CARLSON: I think that that--no, I mean I think it's, that is, you see that at the CDC in macrocosm, but it happens in microcosm, too. I think that, you know, the exhaustion that people talk about within healthcare right now is internal and external, a lot of it is definitely external. There was a lot of camaraderie within that initial response, and even now in, you know, we're doing this together, we're all exhausted, but we're exhausted together. But, but there is 00:37:00also internal tensions that are always going to be present, and those make the responding that much more difficult.

Q: The shortages of equipment and PPE [personal protective equipment], how did you get around that? Wait a minute, there's a couple questions here. There's a lot of questions, actually! You had the shortages of PPE, why do you think that there was shortages? Also, when did testing start become part of your daily or part of your intake? Last one, how many patients do you think you guys went through in those first months? I mean, it's hard to figure out who had TB, who was actually a COVID patient, who had flu, without testing.

CARLSON: Yes. Yes, so we did it, so at first, you could only test the health department, right?

Q: Right.

CARLSON: It was get the patient in with respiratory symptoms, so keep in mind, 00:38:00it's still flu season.

Q: Right, right.

CARLSON: You have to get them isolated, so we figured out how to get isolation beds before we had our COVID unit up. You couldn't put them with COVID patients, because you didn't know if they had COVID patients, you had a separate "I don't know what you have" bed that you put people in. That had to be like a single room with a shut door with airborne isolation, etc. These people could decompensate very fast, so it had to be in the ICU. Then you would ask, the physician who wanted the test would call our phone, and say I've got somebody for testing, and you would sort of check off the boxes that you know that the health department is going to ask, if they met the health department's criteria, you then had to call the health department and be like, I've got this person, here's, you know, I need permission to send you a sample.

Then, you know, once they said yes, we agree well this person can get tested, we 00:39:00would get the swab. Actually, we very quickly ended up with a shortage of swabs, a shortage of viral media. The equipment actually wasn't the problem, although we bought a bunch of BioFires right away. We ended up having a lot of money right away to do equipment, but it was all the stuff! The swabs weren't there, the viral media weren't there, the PPE to get the stuff was in shortage. You had to be really like, in some ways, very judicious about what you were going to do, and the lab was great, they ended up setting up a procedure where they would test for flu first, and then they could use the same swab, if flu was negative, for all the other respiratory viruses. Then if those were negative, then they would send what remained, which was still enough, over to public health to--but that took a couple weeks to get going. To do the rest.

That was the initial procedure, like you would get the person in, you don't know what they have, you test them for flu, you test them for the respiratory viruses, we actually were taking two swabs in the beginning, and then, you know, we'd send it to public health. Then public health would do the testing, and it would take five days to come back.

Yes. Once the testing rolled out and was available, it was a kit, but you could only get like a certain number of them, right? It was all done through central VA, like national central VA. We would get thirty a week, and it would be like which thirty people are going to get our in-house test, and who's going to be sent to the public health department? Then it was a whole triage thing of like, is this person going to be in-patient, are they very sick? Yes, okay they get an in-house test. This person is not going to be in-patient, nope, they don't get 00:41:00an in-house test, send it to public health. There was that whole thing. It took at least two months before we could do all of our testing in-house and have the supplies and things to do it. Just the administrative of like, going back and forth with, you know, public health to get the paperwork in, to get the results back, etc., took people and time, and it was a twenty-four/seven operation, so.

Q: Sounds like a lot of paperwork.

CARLSON: In the meantime--yes! In the meantime, they have to stay in this protected environment. You're using up N95s, because you can't move them out of an N95, out of an isolation room for COVID. You can't move them out of an isolation environment for COVID until you confirm they don't have COVID. Initially, we actually didn't require that, we said if you have an alternative diagnosis, they can go. Often, we would get an alternative diagnosis, and then 00:42:00somebody slipped through, and it caused an outbreak of COVID.

Q: In the hospital?

CARLSON: In the hospital, yes. Which is not uncommon.

Q: No. Early on, this was new.

CARLSON: It's not uncommon, but it was a bad deal. Actually, it stopped when we implemented full universal masking with cloth masks in the middle of April. But it took us, you know, a couple of weeks to really stop the transmission.

Q: How many patients were you seeing early on? Like when you were at full-blown, and you still didn't have real good testing, and you had--

CARLSON: Initially--

Q: --to go through the health departments, and--

CARLSON: Initially it still wasn't a lot. Like our first patient, you know, for the first bit, it was only a couple of patients, maybe two to five that were in the unit at a time. But then very quickly what happened was, even though we were only seeing a smattering of patients a week, the ones who were sick, they stay 00:43:00sick, right? This is not a quick disease, often. Sometimes it is, sometimes it was very fast. But more often than not, what it was, it was a very quick onto the ventilator, and then you staying on the ventilator, and slowly deteriorating. There were patients that were there for weeks, weeks, I think some for months, you know? The death rates were just, they were high. They were high. If you landed in the hospital, the chance of passing away was extremely high. If you went on the ventilator, the chance of passing was incredibly high.

I literally, from that time, remember one patient who came off the ventilator in 00:44:00that first wave, and got to go home, and it took him months. The rest of them passed away. We were trying, we were part of the--we were testing convalescent plasma at that time, hydroxychloroquine was used for the first couple of weeks until the data clearly showed, you know, little benefit, and then that was stopped, you know, people were, we didn't yet know about steroids helping, so for the first few weeks, you know, we weren't using steroids, and then we started, that seemed to have some benefit. Proning, we didn't know about proning patients in the beginning.

Q: Proning?

CARLSON: Which is, it's turning people on their other side.

Q: Oh okay, got you.

CARLSON: Yes. To actually put them in a prone position. We didn't know about that. For like the first few weeks, we weren't doing that, and then, you know, after a couple of months that was something, people had tried that said yes, that could work. We don't have ECMO [extracorporeal membrane oxygenation] capability, so we were never a hospital that put people on ECMO, but people could be transferred out for ECMO.

Which is basically like, you put two big lines into a person, and you circulate their blood through a machine.

Q: Oh my gosh!

CARLSON: Which acts as their lungs, because their lungs don't function. I mean you're still oxygenating their lungs, they're usually still intubated, but for the most part, you know, it's an external lung. That's, it's bad when somebody goes on ECMO. It's very dangerous, because you know, you can bleed, you can have strokes, you can clot, it's tough.

Q: I'm going to ask here, the mental health burnout on the staff, how was that handled? How-- were you on adrenaline the whole time? This is a long period of time.

CARLSON: It was a long period of time, it was, I think I would say it didn't calm down from March until probably June, June/July. Yes, we were all burnt out, 00:46:00we were all fried by the end of it. I think that we were all very aware of that, and again I had a wonderful boss, and so he would say you need to take vacation dates, so I did. Obviously, you didn't go anywhere, I just sat in my apartment for a long weekend, but I took, I think it was either in April or May, I managed to get two days where it was just, I'm off. That helped, like I said friends and colleagues helped, but it was, you ran on fumes, because there was no other choice.

Q: It almost sounds like you were in a war. You were constantly , on a battlefield, and every time a patient came in, it was hard to evaluate so quickly, and then seeing so many patients not make it, that has got to wear on you.

CARLSON: Yes, it's hard because you know what's going to happen if the person 00:47:00goes on a ventilator. I mean I remember one guy, yes one guy who went on a ventilator minutes after I left, and the last thing he said to me was, "I'm scared," and I'm like, I know. You know, but what can you say? He died a couple weeks later, never came off the ventilator. I think that, you know, that reality was, we were all living it, so we all felt that kind of analogy to being in the trenches, right? That's common in medicine, because it happens a lot during residency, those same exhaustions, but this was different because it was worldwide, global, everything's upended kind of thing. I was, in a way, lucky that I didn't have kids, and don't have a spouse, and so I didn't have to worry about that.

There were people who, you know, were living apart from their families because 00:48:00they were worried about it spreading. There were people who, you know, would take off all their clothes as soon as they got home and went straight to the shower, and then like plastic bagged their clothes so that they wouldn't spread it to their family. We didn't know at the time how well or not well it spread by touch, so there was a lot of that. Yes, I think everybody from that time, and I'm guessing, you know, even through to now, it may even be more pronounced, I haven't been in the hospital in a while, but you know, that sense of you're living through a war that--that is invisible, right? Most people don't see that going on. I just, I'm fortunate to have a lot of people I can talk to about it, and so that, you know, helped a lot.

But I think, yes, I still, even right now, even with Omicron going on, and Delta happening, I just, I look at it and kind of everybody else is going about their 00:49:00daily lives, and you just know it's still a warzone in the hospitals. If not more so than when it was when we first got involved. here's some stability to it, right? There was a lot of chaos and a lot of unknown that resolved itself to a certain degree by kind of the summer. One of those was masks and N95s, which--

Q: That included the homemade masks too? Yes.

CARLSON: That included the homemade masks, though by the time of the summer came around, there started to be supply that we were able to find in other places, and that the VA was able to find as a national VA, and things like that. There was nothing in the stockpile, I think that was, you know, that was a misunderstanding of mine, it was a misunderstanding of many people of just what the stockpile was meant to do. But I should say, I was getting my master's in public health all during this time, in fact I was also in courses.

Q: Oh my!

CARLSON: Yes, so I had to take the spring term, the fourth term, which is March through May, off. But then I restarted in June. My capstone project was on N95 shortages, and what happened. Essentially, there were a couple of things. Most manufacturers manufactured in China. There really are, so it's larger, you've got me on a tangent. Or I'm getting myself on a tangent.

Q: No, it's great! This is important.

CARLSON: In the United States, and in fact around the world, most N95s and other respirators are not used in healthcare. They are used for construction and manufacturing. That is like, seventy percent of the supply is in construction and manufacturing. The needs in construction and manufacturing are different, so 00:51:00most of those respirators, I think most of those respirators, most of those are valved, so they have an exhalation valve, so your breath goes out unfiltered. Now it turns out that that valve is still pretty good at filtering, and it still works pretty well, you know, as that. But at the time, we didn't know that, so there's, you have this huge supply.

The thing is, is that, so the biggest customers of these companies are not hospitals and healthcare systems. They are manufacturing and construction. When there's a shortage, the contracts that a business is going to fill are going to be the contracts of their most lucrative customers, which is going to be construction and manufacturing. One part of this was the massive supply of N95s that were dedicated to construction and manufacturing did not get rerouted to 00:52:00healthcare fast enough. That's one thing that happened, that they remained in construction and manufacturing, and didn't get pulled down to hospitals where they were needed.

Second thing that happened, in healthcare, there are really only about three major manufacturers of N95s for healthcare. Healthcare N95s, traditionally, have needed approval by the Food and Drug Administration, because they are a medical device, they're used in healthcare, so they're technically both an N95 and a surgical mask, and have met the criteria for both the FDA [Food and Drug Administration] and NIOSH [National Institute for Occupational Safety and Health], which is part of the CDC, the National Institute for Occupational Safety and Health. There's a whole convoluted, you know, regulation scheme that's very important for making sure that they work, but it is very intricate, 00:53:00and detailed, and hard to deal with in an emergency.

Those N95s, again, there's really only like three manufacturers, a couple, maybe a smattering more, but when you broke it down, it's not a whole lot, and most of them are not manufactured in the United States. This pandemic, because it started in China, all of that supply that had been manufactured in China was used in China. In some respects, it was actually, because COVID wasn't anywhere else initially, they weren't needed other places. It was, you know, everybody was like yes, the pandemic in China, you know, they need the respirators, they don't have enough equipment, and the government was essentially requisitioning everything that was manufactured in China. Had it started anywhere else, this 00:54:00disaster probably still would have happened, but it would have been different. That took this huge chunk of U.S. supply.

It was clear in China that there were consumer shortages by the first week, that is reported in the news in Hong Kong. It was clear to manufacturers like 3M that there were enormous shortages by January twenty-first, which is when 3M picked up its manufacturing. But manufacturing requires a lot of, so it requires polypropylene, which is a plastic, but that makes, it's used to make a cloth, the filtering material, and that requires specialized equipment. Well, that equipment is only made by a few manufacturers.

There wasn't enough equipment in the United States to make more, so all of that 00:55:00equipment had to be made. The polypropylene had to be found. It turns out, the polypropylene shortage wasn't too bad, but when it came to like surgical masks, which also use polypropylene, not just N95s, there was a shortage of machines to make those as well, so there was a shortage of fabric, so you couldn't make masks. These were also in tension with each other, what are you going to get, N95s or surgical masks, or both? There were shortages of the elastic, etc. Some of the, and the multiple pieces of the N95s are manufactured in different places, although 3M, which was the company, that I studied, did most of their manufacturing for their stuff in-house.

So 3M was actually in the best position of all of the manufacturers, but even they did not have near the capacity they needed to meet the supply. Supply grew, there's some estimates that demand for N95s in that first two months grew by 00:56:00like fourteen thousand or sixteen thousand percent.

Yes. There was, I mean there were just multiple kinds of aspects to this of how, you know, it had to step up, and 3M and other companies were doubling their production every month, which is astronomical, if you think about it, but they still couldn't keep up with the trend. It really, it wasn't until the summer that that supply just started to catch up to a point where we could say okay, we feel comfortable that we have more than like, two weeks of supply. Then though, what happened on the backend is hospitals and clinics and everybody started stockpiling, because we, you know, because everybody was frightened about the supply chain running short again. I think people are still struggling with it, with the implementing. That's how, essentially the way that we dealt with the 00:57:00shortages was by reuse, restriction, and reprocessing.

We, if you got an N95, you used that N95 until, basically until you felt that you couldn't, like there wasn't a good metric to say okay, this doesn't work anymore. Although I did see one attending walking through the halls with a hole in their N95, and I was like oh, that is not going to work.

But most people would stop before that point. There was reprocessing, ways to reprocess N95s that we talked about in the healthcare system, just ways that we would do it using equipment that we had for instruments, but N95s work because they have an electrical charge, so that's part of their build. You had to make sure the electrical charge didn't decrease through that process, so you know, people who are better scientists than I am, the industrial hygiene, and were 00:58:00doing those studies of like how, how does this work, does it still work with the charge? The original inventor of the N95 [Peter Tsai] kind of went through and said you can do this, you can't do that, he came out of retirement.

Q: Wow!

CARLSON: Yes.

Q: Were you autoclaving them, or what?

CARLSON: You know, I think no, I think it ended up being, I want to say either heat sterilization or like a, I genuinely don't know, or a steam sterile, I honestly forget. But essentially you were sterilizing and putting through and sterilizing. Some of them, and it depends on the technique, so some techniques you have to use your own N95 again, so we would have people write their name on them and try to get it back to them. But you can imagine what it's like to try find staff in a large medical center and be like yes, here's your N95. We were 00:59:00reusing face shields, another thing that was in shortage. Gowns were in shortage. In fact, surgical gowns, we had to stop surgeries, not because of COVID patients, but because we didn't have the isolation supplies needed to do surgery.

Yes, so surgical gowns were nowhere to be found because everybody was using them as isolation gowns. Everything in surgery was also like, don't touch, if there's an emergency case, we need these things. Fortunately, we were a government hospital for, in the American billing structure, surgery is how healthcare makes money, and without surgery, you have no money. A lot of hospitals that were running on margins like 0.3 percent, some of them are quite rich, don't get me wrong, there are hospitals with good, solid margins. But even those, like without surgery, they were running in the red.

I know that many hospitals actually furloughed or laid off workers during the pandemic, because they didn't have money, and nothing but kind of emergencies was coming in, and so the surgeries that would usually fund healthcare were gone. That was--

Q: Wow, I did not know that.

CARLSON: Yes, and so this is why there's a huge push to put surgery back. Not to say that there's not also people who have delayed surgery, or who are in pain, or you know, who have cancer, who need the surgery, but in all honesty, the biggest push is that they need to be able to fund their COVID operations. Because COVID operations aren't funding themselves. You have to have a source of revenue. Fortunately for the VA, that just came from Congress, and honestly for a lot of healthcare systems, I think it's been through funding. Some of them have been able to stay open, but there are a lot of rural systems that have shut 01:01:00down because they just, they can't sustain it, and without surgery, they definitely can't sustain it.

Q: Wow, I did not know that, that's incredible. All right, we're at an hour here, I wanted to make sure that we got your path to CDC on here.

CARLSON: Yes, yes!

Q: You are, that was amazing, I mean that was so good. Let's kind of pivot, and tell me about how you got here to CDC.

CARLSON: Yes. I have actually wanted to come to CDC for a while. I had started my master's in the thought that I would then apply to EIS [Epidemic Intelligence Service].

Q: The Epidemic Intelligence Service?

CARLSON: Yes, exactly. I knew that that's kind of where, in general, I wanted my career to go, that had been a soul-searching process after I left fellowship. But I learned a lot about myself and what I enjoyed in those first few years, 01:02:00and one of them is that I just enjoy program development, I enjoy thinking about a problem, picturing and putting together a solution, trying to implement it, and see what happens, do you, you know, have success? That had been my job in healthcare epi at St. Louis, and it had been a great experience. But I knew that it was something that I wanted to take out of the institution and onto a larger level. I was kind of going back to my social science international relations roots of what is public health.

That had been on my radar before the pandemic. But I had thought it was a year away, or actually no, that's not true. I had planned to apply that spring, because I was supposed to finish my MPH by that winter. That did not happen, so 01:03:00my MPH got pushed out for another semester basically, because of the pandemic. I was going to apply to EIS and in fact I did, I applied to EIS, but then with the pandemic, and the funding, and the burnout, I'll be honest, it was just, I was so exhausted at the end of it, I was like I got to get out of here. Also, in the process of responding, just the, what my limitations, what I would be able to do in that organization, given the players involved, and the structure of the organization, you know, it's nothing like a pandemic emergency, to make very clear where sort of the ceiling is to what career-wise you're going to be able to do.

I was like, it's time. I'm going to apply to the CDC, they are obviously hiring, 01:04:00because they're expanding to respond to the pandemic. You know, I want to move into the next thing. I was actually at the five-year mark, or just shy of the five-year mark at St. Louis, is that right? Yes, or I was going to enter my fifth year, right, 2016 to 2020. I was about to enter my fifth year, and so that had been--my boss and I had always sort of said, this is a stepping stone position. Then at first, he was like, in three to five years I expect you to, you know, apply somewhere else. Then later on, he got, in five to seven years I expect you to apply somewhere else. At the five-year mark I was like, "Jay, I just want you to know, I'm applying," and he agreed with it, he thought it was the right thing to do. Sure enough, I got three interviews for things sort of 01:05:00right off the bat.

But one of them was from Mike Bell, who's the deputy director for the Division of Healthcare Quality Promotion. He was starting Project Firstline, and he said you know, I'm starting this project, I don't have a job yet, so there actually wasn't a position, he just cold emailed me, he's like, I have this project we're starting, I need someone, I think you'd be a good fit, let's chat. I said that sounds great, because it was healthcare epidemiology, so it spoke directly to my experiences, it was a brand new project. As somebody who wanted to do program development, this was a great role.

Q: What were the other ones?

CARLSON: The other ones, there was actually a position in the division of smoking and health. Totally unrelated, but I also was, you know, again I was at that time where I was like, let's just see. It was also very interesting, kind 01:06:00of a more diverse role in terms of the different things that I would have been doing, definitely a different subject matter. But still a great group of people, and I actually almost accepted their position, just because it was a fascinating role. Then the other one was the division of global migration and quarantine I think is--yes. They were hiring for officers in airports. They were opening up new quarantine stations, right? They actually offered me a job in Boston, which could have been really interesting as well, but I also turned them down. Many apologies to the people I've turned down, it was not personal.

Q: That's all right.

CARLSON: They were really interesting jobs! (laughs)

Q: Boston is the oldest quarantine station.

CARLSON: Oh, is it really? That's really fascinating.

Q: Yes, the first one.

CARLSON: I guess that makes sense, given its history. No, I mean they were very, very interesting jobs, but the one with DHQP [Division of Healthcare Quality Promotion] really seemed most to fit what I wanted out of my career, and also my one expertise at the time.

Q: Yes, let's talk about it.

CARLSON: Yes, so let's talk about Project Firstline. Project Firstline is an infection control education and training program. The idea for it really existed before the pandemic in Mike Bell's mind, and had kind of been born out of experiences with Ebola and other things where people know what to do, often, but they don't necessarily know why they're doing it, and therefore when events come up that require changing an approach, mistakes get made, or people don't want to 01:08:00adhere to what they're being told to do because they don't understand why they should do it. Most infection control education and training is geared towards nurses, particularly infection preventionists, and physicians. We're then expected to go teach the rest of the healthcare system what should be done.

Mike sort of said, you know, really we need to make stuff that is accessible to EVS [Environmental Services] workers, right? Environmental Services workers. The nursing assistant and medical assistants, so the people who usually take your vital signs when you go to the doctor and get you settled in. That it needs to be available to the clerks, right? To the dieticians, to the people who don't consider themselves healthcare workers, but clearly work in healthcare and have 01:09:00to adhere to these things. The idea was that we were going to build, it was almost, one of my colleagues calls it a startup, right? It was almost like that. We have nothing but money and a lot of people. We need to create education and training. We're all remote, by the way, I moved to Decatur in the middle of the pandemic with my dad helping me along the way.

But I had never met my colleagues, never been to the CDC, and yet here we are, starting this up. In fact, I started it while I was still in St. Louis. I literally went to bed one day and was employed by the VA, and woke up the next day and was employed by the CDC. Like Friday I left the VA, Monday I started at the CDC.

Q: But you were still in the same spot?

CARLSON: But I was still in the same spot. It was very, very weird. But I mean it was fun, and it was a good transition, it was a wonderful team. But we didn't have anything, right? We were trying to say we want to make just another government training. I mean we've all been through--as government employees, we've all been through just another government training.

Q: Yes, we have. Yes.

CARLSON: Yes, and so we know what we don't want, but it was very hard to figure out what we do want. We got in a pickle in a way, because the first attempt didn't go through, it just didn't work. Particularly, we were about to launch things right as the pandemic was getting bad, and the stuff that our vendor had produced was just, it was too upbeat, and we were like, people are not upbeat, and it's going to come across poorly. We said, "nope," and sort of threw out 01:11:00that plan, and then it was like, what do we do now? We were like, my colleague Kendra Cox is a writer who I work closely with, who's part of this project, and she and I were like, we think we can write this out, and if we need something, Abby can just stand in front of a camera and do a video blog, right? We'll just, we'll do a video blog, right? We have the information, it's not like we don't. We have the words, we can write them, that doesn't take long.

We said we've got nothing else-- we've got to run with something, that's what we're going to do. I ended up setting up a studio in my living room, right? I had to buy like a tripod for my iPad, and another one for my phone, and get the lighting all arranged.

Q: Are you still in St. Louis, or are you in Atlanta now?

CARLSON: No, now I'm in Atlanta, so I was, this is like November of 2020.

Q: Okay.

CARLSON: I'm in Decatur, and in the living room behind, right back there. Like there isn't a lot of space, we have a creative director who's like trying to say, do this, do that, you know, Margaret Anthony and Martha Sheeran, who's our sort of media person, getting on camera with me, said what's popping out of your head, what is that thing behind you? No move this way, move that way, get rid of that, do this, you need this. Like we're doing this whole staging.

Q: All remote

CARLSON: Meanwhile, Kendra and I are writing like three scripts a week, and rehearsing them, and then recording them Friday mornings, right? We would record three at a time. We'd do a couple takes of each one, usually it would take an hour and a half, on my iPad I would have the team up on Zoom, and my camera was being used from my iPhone as the camera to get these videos. They are not 01:13:00high-quality videos.

Q: Wow.

CARLSON: As Margaret Anthony said, this is nothing you would put in your portfolio. But it got the information out and into a product. From there, we can run, and from there we bought ourselves time. That was very chaotic beginning of Project Firstline was essentially a series of what we called video blogs that were just, you know, five to seven minutes of me talking about a topic.

Q: All created remotely with people collaborating remotely?

CARLSON: Yes. Everything, but we never met in person the entire time.

Q: Wow, that's amazing.

CARLSON: Yes, it was--I mean it was fun! It was fun, you really, there's a sobering to it, you know, and that goes for all of this pandemic, you're doing this, and again you're serving healthcare workers who you know are in that warzone you're very familiar with, and so it was very much a, I'm having fun but 01:14:00I'm not missing the fact that this is not like, a party moment, right? This is not an oh yay, yes moment, it's an all right, I'm getting this out so that you guys can understand what's going on, and how, you know, how we make these decisions, and why we make them the way we make them.

It's tough because people are not used to the way that we sort of deliver content, so some people were expecting something much more technical, much more, you know, science-heavy, and we were like uh-uh, we're going to explain this in, you know, sixth-grade level language or below, I'm using germs, not pathogens. You know, I'm going to talk about dirty, not soiled, right? I'm not talking about hand hygiene, we're going to say clean your hands, we're very anti-jargon. Even within the agency, that's hard. That was really hard for people when we would come up and we'd be like, here's how we're going to talk about it, and they were like oh, but you know, we need to use this specific word, we're like 01:15:00no, no we don't.

Q: Who are your customers for the vlog?

CARLSON: Really, it's meant to be frontline healthcare workers. It's meant to be something that people can listen to, they shouldn't even have to see it, right? We made it a video so you can watch it as a video, it's up on YouTube, but it's something where, you know, if an EVS worker, Environmental Services worker, says I want to know what in the world a variant is, what's a variant, what's a strain? Okay, I made a video, I'm going to tell you exactly what that is, right? Or what is a virus, because you know what? Most people don't know. Explaining exactly what a virus is, without using words that people don't understand. If you want to know what asymptomatic spread is, or what do I mean by respiratory droplet? How does COVID spread by respiratory droplets, what is that, right? 01:16:00Really getting at that level of things, and really explaining it like you would in a high school science class.

But respecting that they're adult workers, right? You're not going to get too cutesy with everybody. That they can go and kind of understand words that are being tossed about that sometimes people don't define and explain well.

Q: Sure.

CARLSON: Also, things that they're doing, like why should I wear an N95 respirator, right? What do they do? Okay, well how do I, somebody said I should do a user seal check, what's that? How do I do it? Why do I do it? We focus a lot on this why question. Why am I doing this? Why am I doing this, this way? You want to set up negative pressure, why? Why do we have negative pressure, what is that and why, right? That's a big theme of ours, to answer the why for people who really often aren't talked to, and that, you know, that was another 01:17:00experience from the initial months that was important, was in the town halls that we did, you know, being able to have our shuttle drivers, and our maintenance crews, and our environmental services workers, and our clerical staff like see my face up there, know who I am, so that if they see me in the hall, that they can say hey, Dr. Carlson, I've got a question.

To hear the answer from me, the person who's making the rules, right? Or one of them. That, you know, they don't feel like they're being made over their heads, that there's somebody they can go to with complaints and questions, and things like that. We were trying to replicate that, to a certain extent, on a larger level, which is really hard, right? The CDC sometimes seems like this big nonhuman entity, and it's on purpose. We know, a lot of us, we are not, we don't 01:18:00want to be in the limelight, we don't want our faces plastered up there. Not because we want to hide behind our desks, but just because it's such a team effort, right, that you're not there to make yourself known.

But that also means that people don't know you, right? It's just the CDC says, well who are they? Who is the CDC? Well, the CDC is us. To get up there and say I'm Abby Carlson, I'm the CDC, and here's what I say, and I, we as the CDC say this, and you can hear it from me directly. That's been a big push. Which you know, I know we're running low on time, but another very important part of this is most of what we do as Project Firstline doesn't happen inside the CDC. We've had this huge, huge partnership.

Professional organizations that we have funded, like the American Medical 01:19:00Association, American Nurses Association, the National Council of Urban Indian Health, the National Indian Health Board, the National Hispanic Medical Association, all of these organizations that are very interested in bringing education and training to their members. American Hospital Association, through their Health Research and Education Trust [HRET], who's then funding like the American, I think it's American Society of Healthcare Engineers, American Academy of Pediatrics, the list goes on, and on, and on. I want to meet everybody, because they're each important in their own way, but the point being that they are to help then, help us take what we, the technical information, and make it relevant to their audiences. All the states and jurisdictions have been 01:20:00funded similarly to do the same for their audiences, for their states.

Different states are doing that in very different ways. Then there are some academic partners who are doing fundamental research on infection control for us in areas where we think there are really big gaps in knowledge, and have found some very fascinating things about how aerosols move, particularly in operating spaces, how errors are made in infection control on the wards. They're doing a ton of just wonderful work. Then, you know, we've been engaged with community colleges, trying to integrate infection control into health professions curriculums at the community college level. I'm working with that group of professors, who are also almost all, if not all, in the health professions themselves and are also working or have recently worked. They were an excellent 01:21:00group to talk to in terms of their experiences, and just getting to how does it make it relevant for like a respiratory therapist, what do they need to know? You know, what does somebody who's in a nursing assistant curriculum need to know?

All of that partnership is also Project Firstline, and in fact the bulk of the work that is being done is being done in those partners. Then CDC is trying to provide that core, you know, now moved onto much bigger things with RTI [Research Triangle Institute], who has partnered with us to make stuff. Now we're moving on kind of to a much larger and more sophisticated set of things that does not involve my living room. But yes, so we're still in the startup phase in many ways, but it's a massive, massive undertaking.

Q: Sure! This pandemic has actually shined a light on health equity. It sounds 01:22:00like Project Firstline has a part of that as well.

CARLSON: I'll tell you, one of the courses that I took during the pandemic, and at the end of my master's was a history of public health. Pandemics and infectious diseases outbreaks in general almost always, throughout history, have shown, and shone light on health inequities in society.

That is, you know, one of the features of the upheaval that comes with them, and this one is no exception. I think that for us, you know, we see it as, rather than health equity, or healthcare equity, which is really what we, both of them apply to what we're doing, but instead of seeing them as like this thing that you do elsewhere, saying okay, this project is meant to do this education and 01:23:00training, and what that does for healthcare equity is to increase the quality of healthcare across the board, but particularly amongst populations that have not experienced healthcare equity as much as others. What I mean by that is, I'm trying to think of a way to say this. If you go to say Barnes-Jewish Hospital or the Mayo Clinic, you know, you have a team of people who have a certain level of knowledge and capacity about infection control.

They've got experts, right? They've got an infectious diseases staff, they've got a system in place to train people, like they've got all this stuff. If you go to a critical access hospital in rural Missouri, they don't have the 01:24:00infectious diseases staff, there's one infection prevention nurse. They don't have the knowledge, right? The care, as in the level of infection control that you're going to get, may or may not be the same, right? Our goal is to say okay, those places that don't have that expertise, those are the places we're going to target, and we're going to bring our expertise to you and help you build your own internally so that your staff have the knowledge they need to give good infection control patient care, right? Because infection control is part of your patient care. That increases the healthcare equity of that space. That's one part of what we do.

The other part of what we do is that we take people who don't usually get educated about their own occupational risks, right?

Healthcare workers who are, you know, who may not have equal access to knowledge about the risks of their work that say, a physician or a nurse does. Even though nursing is one of our target audiences. We say to those healthcare workers, we are going to increase your health equity by giving you the knowledge to understand what your health risks are in the workplace, and how to decrease them, and how to get your organizations to decrease them, and going to the organizations and saying you need to protect these workers, and here's how you do it. Here's, you know, a huge why you do it, and here's what the issues are. It's really focusing in on those aspects of healthcare and health equity for two kind of different populations, but through one process, which is increasing in educational level across the board for frontline healthcare workers about 01:26:00infection control.

Q: I look forward to all of that. All right, I'd like to just kind of turn towards CDC.

CARLSON: Sure.

Q: You know, well we are on CDC, but CDC has really had a high profile during this pandemic, and the media has been somewhat, sometimes kind and not so kind, especially when it comes around our guidance policies, and perhaps the effect of misinformation. I just wanted to get your thoughts on some of those topics.

CARLSON: Yes, and so I think a lot of it has fluctuated during the pandemic, in many different ways. You know, and we've talked before about how, you know, changes in administration mean changes in approach, that's typical for anybody who works in government, you know, you expect that, that there's going to be a 01:27:00shift from one administration to the next. I think there was a lot of suspicion, some of it justified, about what we did in the initial part of the pandemic. But I also think, you know, I think that CDC exists in a world of a lot of experts, and we are certainly not the only ones, right? There are lots of places in the pandemic where there hasn't been scientific consensus. There's lots of places where there has been and there's still controversy, but there's lots of places where, you know, for instance, in community masking, in whether or not we need N95s, in whether or not we need screening, in whether or not to recommend canceling procedures or whether to recommend reprocessing N95s.

All of these things where, you know, experts still are debating the exact transmission dynamics, to some extent. The media have to wade through that, and struggle, and I think oftentimes what that means is that they end up saying well the CDC is wrong because all of these other experts say this other thing. Sometimes it's actually a complete misunderstanding of the definition of the same word, so airborne is one of them, that's a big controversy, and one group of people uses the word airborne one way, and the other group of people uses it with a different definition, and so they're sort of cross-talking to each other.

Some of it does have to do with just degree of risk that people are willing to assume. Some of it has to do with, you know, political pressures, and I mean 01:29:00that with like a lowercase P, in the sense of everybody has interests that have to be balanced, right? You have them coming to the CDC or government and saying well, in my perspective, it should be this! But in my perspective, it should be that, because this is the interest that I have. Politics with a lowercase P is the act of reconciling all of those various interests. CDC has had to do that to a certain extent, all the while keeping their eye on the fact that their goal is to protect people, right? Their goal is to release guidance that is going to protect people. It's very--

Q: Plus--it's an ever-changing virus, as well.

CARLSON: Right! It's, well and then there's the whole issue of variants. Just when people, you know, are used to one thing, the next thing comes up, right? Delta comes up and you have to respond to that, after what was a beautiful few 01:30:00months of summer where there was almost no transmission.

Then, you know, you go into the end of Delta and you think okay, maybe that was the winter wave, and then oh no, Omicron is up. You know, should we have travel restrictions or not? Is that, honestly the question was, is that a racist thing that is being done? You know, are you targeting South Africa unfairly? Are you targeting southern Africa unfairly? That accusation comes up, and then how do you--so people have businesses, and livelihoods, and lives, and children, and two years in, you know, people are just tired. Managing all of that, and I, you know, it is a struggle because the CDC is not a fast organization, it's a very deliberative organization in many ways. There's many, many people who end up having a say in how things get done.

That can be very frustrating internally and externally. At the same time, you know, even if you figure it out within the agency, then you have the rest of government, right? You can figure out one thing at the CDC, and they can go out and then, you know, you have a whole other group of people who weigh in. Fortunately, I'm way on the bottom of the totem pole on this one, so I sort of watch it from above, and seeing it happen. You understand the frustrations on both ends, right? You understand the agency frustration with trying to do the right thing, and never seeing a human being able to win on the scale of public opinion. Then you understand the public, who is like this is not clear, or you didn't, you know, you sprung that one on us, what in the world is going on?

You know, some of it comes from within the CDC, some of it doesn't, the CDC gets blamed anyway, and you know, that's how that goes. In the end, I think that in 01:32:00general, those of us internally will say we recognize that there are faults, and the appropriate response right now is to try to fix them, not to sort of decide that it's the fault of somebody else.

They're doing that. There's an active effort to do that, and has been this whole time, and it's every growing and changing. But I think it's also something where in public health, not that it comes with the territory, this has been a particularly brutal pandemic for public health, with just the viciousness that's been directed towards the profession as a whole. But, I also think that there's a certain degree to which it's never been anybody's favorite group in the government. You're just kind of like, I'm going to, I am going to sit here and 01:33:00do the best I can for people.

Q: Oh, I love that.

CARLSON: Because I don't have control over a lot of things, but I can make sure that what I put out for people is as excellent as I can make it, and I can make sure that people that are traditionally not thought about get thought about, and that the information gets to them, and I can put in, I can make the push for that, and I'm in a place where there are things I can control. I think you, you know, we're all trying our best, some of us definitely are like, we need to improve, and how do I improve, and so that's, you know, you sit there and you're like, how can I make this better, how can I make the communication better in my little corner of the world? But yes, you do what you can, recognizing that there's a lot that you just can't control.

Q: So true. All right, so I want to step away from CDC now and talk about, because this pandemic is ever-encompassing not just your work life, it also encompasses our personal life, and sometimes there's a very, very thin line between the two of them, especially when you telework. Personal life, navigating this pandemic, you and I had spoke about how there is reverberations of this into future generations, and also a lost generation of people.

CARLSON: Yes.

Q: Would you please expand on that? It was a great conversation, and I want to get this recorded.

CARLSON: Yes, no, no. I think to start with the lost generation, and really lost years, I think all of us have lost years, right? There was an expectation that I would do something in 2020 to 2022 that I did not get to do. Even though my career as an infectious disease physician and healthcare epidemiologist like, I 01:35:00was trained for this time, right?

My career took off. But in my personal life, there's so much that I was supposed to do that didn't get done. Even the simple things like dating, you weren't going to go on dates for the first year of the pandemic, and even now, it's not easy, as a single person. I didn't have children, I'm extraordinarily lucky. I think that there is a generation of children, and I'm not entirely sure where this is going to land, but that really is going to be a sort of, what I call the lost generation now, but might actually turn out to have been impacted by the pandemic in a really profound way that is positive, right? I don't know what's going to happen with those kids, the kids who lost, you know, very important years in school, and whose childhoods will be very defined by what this pandemic 01:36:00was, and what will happen to them, and what they will do.

I think that there are a number of children who have lost a caregiver, right? The estimate I think was, it was extremely high, I forget the exact number, but it was--there's a lot of kids who have lost a caregiver in this pandemic. Those children will go on, you know, with that weight, that's not going to go away ever, it won't, ever. I say that to get to your second point, as somebody whose great-grandmother died in the 1918 influenza pandemic. My great-grandmother was pregnant in 1920, and my grandfather was two years old, and my great-grandmother passed away from influenza in that second season. My grandfather grew up without a mother.

That, as well as sort of the depression that my great-grandfather went through 01:37:00because of that, and the extended family, and extended family dynamics that happened to take care of my grandfather, all of that impacted the way that my grandfather kind of went through the world. That in turn has impacted his children, and they, you know, they can clearly trace that, which is my mother and her siblings. This is, you know, this is also the generation that went through the Depression and World War II, and so even still, with all of that, the fact that my grandfather grew up with one parent just has implications that have gone on for the last hundred years, and I think that, so for families like mine who see that, who know about those pandemic deaths from the 1918 to 1920 period, you know, we look at this time and it's like yes, that's not going to go 01:38:00away, and a hundred years from now, they're going to have a family story, and there will be implications of what has just happened for the family, even then.

I think that's huge. I think the other thing that we had talked about that I would say is like, you know, going back to the war analogy a bit, where you don't necessarily recognize it as you're living through it, but one of the other public health courses I took during this pandemic was on demography. Looking at simple things like life expectancy, and births and deaths, this pandemic will appear on life expectancy charts for the United States like a famine or a war would, where life expectancy drops precipitously, where excess deaths, in fact a 01:39:00couple of days ago we crossed the one million threshold. Anybody will be able to look at a simple line graph of life expectancy and go something big happened there, right? Something very unexpected happened there.

I don't think people have fully absorbed the implications of that, because they're too busy trying to live out their daily lives. But that's the kind of massive thing that's going on right now, and so there's always kind of this thought in your mind of what is that going to look like when we look back on it? Because right now, when you're in the middle of it, you know, you still wake up in the morning and do your thing. I mean yes I didn't touch another human being between October 2020 and April 2021, quite literally, between the time my dad 01:40:00left after I moved, and the time that my parents came back, when they got vaccinated, and when I got vaccinated, I had not touched another human being.

That is just, that doesn't happen. But I didn't think about it all that much until it was over. I think that there is all of that. Then there's, you know, yes. There's a lot of things going on that are just kind of, especially at the beginning, what I said is there's the processing of that initial time, I literally pocket it in the back of my brain in some way, right? It was just in this corner, and I was like, I'm not going to probe that, because I don't have the time, the energy to look at what I just went through, you know, I need to keep going. I really didn't start processing that until probably last summer.

Q: Sure, the inertia kept you going.

CARLSON: Yes. For sure.

Q: We didn't even talk about vaccine.

CARLSON: Oh my gosh. Yes no, getting vaccinated, vaccine was a big deal. My grandmother is ninety-eight, she's about to turn ninety-nine in two months.

Q: Congratulations!

CARLSON: Yes, she lives on her own in assisted living, but I just remember like, when she got vaccinated in that first wave, and then my parents getting vaccinated, and then finally I, I went to the Georgia Convention Center, yes, out by the airport. I snagged an appointment, that was a tough one. Just as it opened up to everybody, so I was one of the first people when it finally opened up. I didn't cry, but I--it was, you walked out of the door and it was just like, wow. Wow. I mean it was really like, you know, I put on my calendar when 01:42:00my, you know, two weeks after my last dose is when you're considered immune, right? It's like, that's the day, after that day. Just that thought that okay, I can, I still worry about getting sick, but I can worry much less about dying.

Q: Sure. Yes. When you got vaccinated, was that your first person that you actually had seen, or been close to, in quite some time?

CARLSON: No! No, no, no, actually so--yes, that was the first--no, no, no, you're right! That's the first person. That's the first person that, I hadn't gotten my hair cut, I hadn't, you know, we didn't go home for Thanksgiving or Christmas, everybody spent Thanksgiving or Christmas in their own houses.

Q: Oh yes.

CARLSON: Yes, so that was the first time.

Q: Wow.

CARLSON: Right? Then the second time was a couple weeks later when my parents came.

Q: Sweet.

CARLSON: Yes. Yes, so they were fully vaccinated earlier, they're over the age of sixty-five, so they both came down once they were--

Q: Your grandmother is fully vaccinated, I'm assuming?

CARLSON: Yes! My grandmother is fully vaccinated and boosted, I mean everybody's gotten their boosters now, and--

Q: Yes. Such a difference, like I was only, how long did I take to get a vaccine? A whole, was it a year or a half a year? I can't remember now, it was December.

CARLSON: It took a year. No, less than a year, less than a year.

Q: It was less than a year, yes.

CARLSON: It was November of 2020 where people started getting vaccinated, December. Yes, and then there was the whole side effects thing, which actually that was another thing we didn't talk about, but I was, that was one of the side projects that I did as Project Firstline had a little lull, they were recruiting physicians to investigate the side effects, and so there were just a bunch of us like twenty, thirty, forty of us eventually who were combing the VAERS [Vaccine Adverse Event Reporting System] database, the Vaccine Adverse Event database. Like you'd just sit on the phone and call. It's pretty funny, because you say 01:44:00you're from the CDC, there's a lot of people who don't believe you. [laughs]

Q: Oh, really?

CARLSON: I had people call their state health department being like, is this person really from the CDC? Then they would call me and be like, can you like, send me an email from the CDC? A lot of people aren't familiar with public health law, so they were hesitant to give you details. Patients, of course, are happy to tell you everything.

Q: Oh yes.

CARLSON: But we were mostly talking to healthcare providers, because in order to confirm the case, you had to talk to the medical providers, and so that, I mean that's what the invest--the investigation looks like a lot of us on our couches with a laptop, calling people via Skype, so that we were calling from a government number, and trying to find a physician or nurse who knew what in the world was going on with these patients. There's a massive database, and we were 01:45:00just, we were training people one after the other.

Then of course, it was moving so fast, and leadership had their attention on it, so it would be like leadership wants these things by tomorrow, and it's 4:00 P.M., right? You're not going to find physicians to confirm these cases, but you're going to go and do it anyway. Why? Because that's what you need to do. Combing through charts, and it was actually, it was really edifying in a lot of ways to be part of that, to be part of the, okay, here are the risks and here are the not risks. Like here are the cases that really, this is what is going on. Myocarditis was the same way, that came up as we were working on the thrombosis syndrome for the Johnson & Johnson vaccine. The myocarditis findings just started to pop up.

Then, a bunch of us got shifted over to myocarditis in the kids, and that one, 01:46:00again, another gratifying one, when you're looking at it and you're saying okay, I feel good about this because these kids seem to be doing well, right? Even if they get myocarditis, it seems like from the conversations with their physicians, from the charts, that things are going okay. Just being able to do that investigation and be a part of that was also just another highlight, that was my actual time on the response, that was the time I spent doing actual response as opposed to in this training and education corner of the world.

Q: Yes, okay. It was a little bit of contact epidemiology.

CARLSON: Oh yes it was definitely like the classic shoe leather epidemiology, but without walking, it's all--

Q: Without walking, yes.

CARLSON: It's all computer now, it's all Skype calls now. Or Teams calls these days.

Q: Okay. At the end of our time, I'm sorry to say.

CARLSON: No, no, no, absolutely.

Q: But I wanted to ask what else we haven't covered that you'd like to share.

CARLSON: You know, I mean part of it is, it's not over, right?

Q: Right.

CARLSON: This is, we're in year two, but we're transitioning out, hopefully.

Q: Right. We are, we're trying to like, start collecting these stories and then maybe in two years, recollect the same people, so I'm hoping that you'll be around, that I can do that with you.

CARLSON: Oh, that would be awesome. You know, I think the other thing that I, we sort of touched on, but--not sort of, we did touch on it, I think I'd just reinforce, the incredible loneliness of some of this. I think that, you know, especially for people who don't have family they live with, or people they live with, the amount of solitude, and I'm a pretty strong introvert, but the amount of solitude that has been inside these last two years is difficult, right? I think many of us have come to the realization of being social beings, right? 01:48:00That we, as human beings, you know, we enjoy interacting with people, and being a part of people's lives, going out to restaurants, going out to take a walk even. There, you know, some have been more forthcoming about that than others, some of us are more risk-averse, and so I've rarely, I can count on one hand the number of times that I've stepped in a restaurant in the last two years.

But I think that right now, as a society, we're really struggling with being very pulled apart. There's a loneliness that is physical, there's a loneliness that is emotional, there's a loneliness that is political, there's a loss of cohesion, a loss of sense of, you know, neighbors, and community, and 01:49:00friendships that, you know, I hope comes back relatively quickly, in fact in some ways I kind of hope that as restrictions are lifted and rates go down to near zero, with fingers crossed, that people will actually crave that and come back to it, but the amount of division in the country and in society as a whole, it's not simple. It's not a black and white thing, it's very complex, and it's very hard, it predates the pandemic to some extent, but was made astronomically worse by it.

I think that there's this kind of communal loneliness that's very different that it will be interesting to see what happens in the next two years. But for all that technology made this a very, especially for those of us who have, you know, 01:50:00white collar jobs, who can do jobs at a desk, it made it a different kind of pandemic, it also has pulled people away from each other.

I mean not to end on a hard note. I mean in some ways it's pulled people together, right? There are definitely ways in which my family sees each other more, because we all Zoom now, right? We all are able to get on video conferencing, you know, I see my grandmother, my grandmother can Facetime.

Q: Right, technical skills in people have gone up.

CARLSON: Right! Right no, for sure. There's much, some of it, in our loneliness we have reached out, and there's ways that we've come together in very significant ways that hopefully will stay. But there's also ways that we've grown apart that I think time will tell just what that will mean for us.

Q: All right, I'm going to end the recording now.

[END OF INTERVIEW]