James "Jay" Miller

Q: All right. Right, so today is March 10, 2022. This is Heather Rodriguez for the COVID-19 Oral History and Memory Archive Project. I'm in Newnan, Georgia, and I will be talking to Dr. James Miller, who goes by Jay, who is in Seattle, Washington. We are recording through Zoom. Dr. Miller, welcome to the project. Do we have your--

MILLER: Mm-hmm.

Q: Oh, thanks. Do we have your permission to interview you and record this session?

MILLER: Yes.

Q: Awesome. Well then let's get started. Where were you born? When and where were you born? Excuse me.

MILLER: I was born in New Orleans in 1987.

Q: Let's talk about like your schooling and a little bit more about like, your background. What got you interested in public health?

MILLER: I think I really got interested in it in college by sort of getting 00:01:00interested--I had studied, or I always knew I was interested in history in high school, and was planning to study history in college, and then my first year of college got particularly interested in the history of medicine, and history of infectious disease, not so much in the sense of like, how things were discovered, but more about how diseases and epidemics play out in societies, and how--and sort of what we learn, I guess, about societies from that. Who gets sick, who's perceived to get sick, which isn't always the same thing, who doesn't get sick, sort of the meanings or the messages implied behind diseases, kind of how a society sort of ascribes those meanings. I think that was one element of it. I think I also from that kind of came away with the idea that fighting infectious disease also meant fighting for social justice, and that 00:02:00those two things were really kind of inextricably linked.

Q: How so?

MILLER: Well I think if we, again sort of taking a historical lens on this, if we look back throughout the history of infectious disease, people who are poor, people who are marginalized or minoritized by society in a range of ways are almost always disproportionately affected, going back to the Plague in Europe five hundred years ago, or you know, malaria, where you had poorer people living in low-lying areas where there's more malaria, then richer people living in areas at higher elevation within a city that had less malaria, I think we certainly in a more modern sense, we certainly saw that with HIV [human immunodeficiency virus], and continue to see that with HIV. Of course, I think we've seen that with COVID, as well.

Q: Where did you go to school at? Like to pursue this interest? Did you develop it in college, or did you have this when you were in high school, or?

MILLER: I think I was interested in history in high school, but I didn't really sort of find that niche within history until college. I went to Harvard for undergrad, I was born in New Orleans but grew up in the Boston area and stayed there for college.

Q: Yes. You went to--did you start pursuing public health when you were in undergrad, or did you just, when you went to grad school?

MILLER: Well, so I studied the history of medicine, history of infectious disease in college, and was kind of trying to decide what I was going to do over the long-term, and was thinking about public health, thinking about medicine, or some combination of the two, and by the end of college I was pretty sure that I was going to go to medical school, and took a couple of years in between, but eventually went to medical school, and did a master's in public health along the 00:04:00way, and I think over time, realized that I wanted to, that I enjoyed being a doctor but really wanted to pursue a career that focused on public health. A long answer to a short question, I guess.

Q: That's okay, we appreciate long answers to short questions, so. Tell me about like your family life and your community before the pandemic. We're talking about maybe not like throughout your entire life, but really just more recently, I know, tell me about like, what was it like before the pandemic? Were you practicing medicine I guess is another question I have.

MILLER: Sure, yes. I went to medical school and then did a residency in internal medicine, and finished that, I guess, in, it would have been middle of 2019. Then right before COVID, I was doing a Global Medicine Fellowship, so I was, 00:05:00that was a mix of clinical practice and then some partnerships and research work in Uganda.

At the time, right before COVID I was, things sort of, things changed quickly for me, because I was traveling a lot, right before then, I was working part-time up in Alaska doing clinical work and then traveling to Uganda for these research partnerships, and so all that kind of came to a halt when COVID started.

Q: Yes. Tell me about your time in Uganda. Also, can you elaborate a little bit more?

MILLER: Sure. I first spent time there shortly after college, I spent a year there working as kind of like a program coordinator or project coordinator for a community health worker program that was supported by an American NGO [non-governmental organization]. Uganda kind of became a thread through my life for a while, I continued partnering with that program for a couple years, went 00:06:00and did an evaluation there for my master's thesis, and then in medical school, started working with a different program, spent another year in Uganda, also focused on community health workers, but a different place in Uganda. Then, through my residency and fellowship, continued to partner with that program, mostly focused on what's called integrated community case management, which is basically a system where community health workers provide protocol-based or algorithm-based treatment of childhood illnesses, usually malaria, pneumonia, and diarrhea, which are three of the main causes of child mortality in that setting.

Q: Yes. You said you were working with an NGO-- do you mind explaining what NGO stands for, and then can you elaborate a little bit more, do you want to be more specific about what organization?

MILLER: Oh sure! Yes, so NGO is a non-governmental organization. The first place I worked was a collaboration between Kisoro District Hospital, which is the 00:07:00hospital in one of the rural districts in southwest Uganda, and a non-governmental organization called Doctors for Global Health. Then the second organization I worked with, it was a collaboration between Bugoye Health Center, which was a health center in a different rural district, and Mbarara University of Science and Technology, which is one of the leading universities in Uganda, and then the hospital where I was based out of, Massachusetts General Hospital, in Boston.

Q: Thank you. All right, so this was all, I mean you were in Uganda up until the start of the pandemic, right? Or did you just come back like a little bit before that?

MILLER: I was there yes, off and on until COVID started. I spent I guess a year there in 2009-2010, and then a year there in I guess 2014-2015, and then a bunch of shorter trips in between, a month here and there [a month at a time], and so 00:08:00I think the last time I was there would have been fall of 2019, kind of before COVID started.

Q: Yes. Were you there, when you first heard about COVID, were you in Uganda?

MILLER: No, I think I was in Alaska, which I was working, the way the program worked, we did some clinical work, partly for the, of course, the learning you get from that, and also to help pay our own salaries. So I was, part of my clinical work was up in northwest Alaska in a town called Kotzebue, pretty far north, it's like just above the Arctic Circle, kind of north of Nome, sometimes people have heard of Nome because of diphtheria, and Balto, and all that. It's kind of like the next significant town north of Nome. I think I, I don't know if I remember exactly when I first heard about COVID, but I think, I was in Alaska in January, so I think we started hearing about kind of the news articles and 00:09:00reports coming out of China initially in January.

Q: Yes. Can you describe, what did you think about COVID when you first heard about it?

MILLER: Yes, I don't know if I remember exactly the first time I heard about it, but I think at the time, I think there was this feeling of, yikes this could be really bad, and I also think that maybe SARS-1 [Severe acute respiratory syndrome] was kind of like a false reassurance--not to minimize its impact at the time, but it was, at least compared to what we know now from our experience with COVID, SARS-1 was pretty quickly eradicated. I remember partly thinking about this because my partner and I were about to go on a vacation after I got back from my work in Alaska that month, and so it was kind of like, do we still 00:10:00go on vacation?

At the time I think it was like well, we don't quite know what this is going to be, but we ended up still going on the vacation. I think there was--and maybe it was naïve, but I think there was this feeling of like well, this could be bad, but also maybe it'll be like SARS-1 and it'll be relatively quickly controlled.

Q: Yes. Where did you go on vacation, did you have any like, travel restrictions at the time--or, I think most of those were regulated to Asia, correct?

MILLER: Yes, no not at the time, I think it was kind of before that, this was like in early February of 2020, we were in Chile, in Patagonia. So yes, everything felt pretty normal at that time, and I think that was one of the other strange things is like on that trip, and traveling back and forth, like everything felt pretty normal, and then within a period of a few short weeks after that, it felt like everything changed in our day-to-day lives. I mean 00:11:00obviously people in China had been substantially affected before that, but in those couple weeks after that, that was really when things changed for us.

Q: Yes. In what ways did they change?

MILLER: Well, you know, I was in Boston, which was probably not quite as affected as early, or as hugely as New York was, but I think, but still among kind of the early wave of infections. Things, felt like things shut down very quickly, and I think we were pretty scared at that point. My other clinical job then was working for Boston Healthcare for the Homeless, and people experiencing homelessness in Boston were affected really early on, and so we kind of, we had 00:12:00a sense that it was spreading in that community, and so I think we were worried for our patients, and you know, knew this was a vulnerable group in a whole range of ways, in terms of access to care, in terms of underlying conditions. I think we were also worried or scared for ourselves. At the time, we didn't exactly know what it would to be infected, what the severity would be, we didn't really have enough PPE [personal protective equipment] at the time, so I think I was pretty, I was kind of convinced that I was going to get COVID.

And you know, it was kind of like people needed care, like it felt like there was a real, there was sort of a, I don't know what the word is, like a moral duty to show up to work, and to take that risk. But I think it also felt like, it felt, unlike later on where I was like yes I think we have PPE, it's going to work, I don't think I'm going to get COVID, I think early on, it felt like gee, 00:13:00like I think maybe I am going to get COVID and I remember I had this conversation with my partner about how I kind of thought I was going to get COVID, and like did it make sense for her to leave and go to stay with her family in Pennsylvania? We talked about it, but I think there was also this sense by that point of like, this is not going away any time soon, and so if we did do that [have her stay with her family] it wasn't clear what the endgame would be. So we ended up deciding just to like, hope for the best and we continued living together in Boston.

Q: Yes. Do you want to describe more about working on the--as a physician in Boston during that time? Particularly with the homeless people and your, like the lack of PPE that you guys had? Were there any kind of like, like what did you do when you had no PPE and you know, this very vulnerable population of 00:14:00people experiencing homelessness?

MILLER: Yes, I mean I wouldn't say that we had no PPE, I think the biggest thing was really N95 masks. Because we were able to use cloth gowns and have those washed, and so that wasn't a huge issue, and I think there were concerns about running out of gloves, but I don't think we ever ran out of gloves. So, it was really about N95 masks and I think there was a little bit early on where we were wearing surgical masks, probably because I think early on, we didn't necessarily know if N95s were needed, and also there just weren't enough of them. Then for a while after that, we were trying to reuse our N95s for as long as possible, so you know, you'd wear a mask for a whole shift, and then you'd like, put it in Tupperware with holes in it, or put it in a paper bag with your name on it, and save it for your next shift. So yes, we were never at the point where we didn't have PPE, but it was, definitely sort of felt that, the shortage, at least.

There was at least sort of that brief period where we were in surgical masks, and I think that's when I was like huh, I think I'm going to get COVID. I guess in terms of sort of stepping back from the PPE issue, and thinking about the care system as a whole, one thing is that, and this is kind of, this is sort of a, maybe a much broader theme, but one thing we definitely experienced was the shortage of test kits early on. And I think particularly because people experiencing homelessness in Boston were affected early, like I remember one of the shelters that people were symptomatic, and by the time they got test kits, and tested everybody on that first round of testing like thirty or forty percent of the people tested positive in that shelter. The other shelters weren't quite 00:16:00that bad, but it did feel like man, this is really, we're kind of behind the eight-ball here, or we missed the boat, or something.

And so, quickly because of that obviously these folks didn't have a home where they could isolate away from other people, and so one of the early challenges was figuring out where people could go who were infected but didn't need to be hospitalized, and you know, the hospitals were under a lot of strain then, so it wasn't going to be a situation where like, people who didn't need to be hospitalized could just be in the hospital for infection control. So there were, Boston Healthcare for the Homeless had what's called like a respite facility, which is kind of like an inpatient, not inpatient in terms of the level of clinical care required, but inpatient in the sense that people stay there overnight, or like I guess residential would be another term, so a respite facility where people would stay after they came out of the hospital, or people 00:17:00who were kind of too sick to be in a shelter but didn't need to be in the hospital. And so part of that got converted into an isolation area for COVID, but that wasn't nearly enough beds, so initially we also, we were at a nursing home that had closed down, and that was a bit, that was kind of challenging and a bit chaotic because the nursing home had been closed for a while, so they didn't really have furniture, and they didn't, like kitchens hadn't been up and running, and so from a clinical standpoint it was a lot of patients, but otherwise it was okay, it was more the logistics that were real challenging.

Then after that, we opened up a much bigger sort of, like a low-acuity facility at the Boston, what's the name? The Boston Convention and Exhibition Center I think is the full name, we just call it the Convention Center. That was where they basically divided it in half, and half of it was five hundred beds for 00:18:00people experiencing homelessness who needed somewhere to isolate and be monitored but didn't need a hospital level of care. Then the other side was another, I think five hundred like hospital-level of care beds in case the hospitals were full.

Q: Yes. These other places that you said like they just transitioned into being these places to where people could isolate, was there any kind of like, I know you said that one place didn't have any furniture, but for the other places, did you have to like bring in, did you have to do anything special to convert them, or you know, was it just kind of a--you know?

MILLER: Yes. I mean I wasn't really, can't take any credit for that, I wasn't really responsible for it, but there was, it was like a very rapid construction project, what they did on the side where I was working, for people who were 00:19:00experiencing homelessness, they had built essentially like a, put in a bunch of sort of temporary like, not walls going all the way to the ceiling, but kind of like cubicle walls, so that people would have their own little space, and then a bed in each of those, and I think a chair, and maybe a little dresser or something of some kind, I can't exactly remember what the furniture was. But it was basically a bunch of these little cubicles where, so each person could have a little, their own kind of space, and a bed, and then they brought in like some desks and computers, and whatnot for the clinicians and nurses, and other folks working there. Then we had to set up a whole like, sort of entry and exit area where people would put on their PPE and take off their PPE. So that's really the only piece of the logistics that I was involved in.

But it was impressive to see how much of sort of a rapid transformation it was, just going from this empty convention center exhibition hall to living spaces for five hundred people.

Q: Yes. Tell me about, so this all happened before you even came to CDC [Centers for Disease Control and Prevention], correct?

MILLER: Exactly, yes. This was the second half of my Global Medicine Fellowship, so winter and spring of 2020. Then I started at EIS [Epidemic Intelligence Service] in summer of 2020.

Q: Yes. What made you decide to join EIS?

MILLER: Well-- I had applied, and made that decision before COVID ever happened, in the summer and fall of 2019. Yes, 2019. Sorry to confuse my years here. But yes, before COVID started. I'd, that [decision] didn't really have anything to 00:21:00do with COVID, I think I'd really enjoyed the research work I had done, but had also kind of realized that the parts that I enjoyed most were the more kind of hands-on, on the ground work in Uganda, building those partnerships and figuring out how to make the program work, and realized that as you move forward in a research career, that becomes a smaller and smaller part of your job, and so I think I had a sense that working in public health might be a better fit for me, and would have me sort of more involved in those like, day to day, how do we make things work, building partnerships. I think I chose to do EIS really to, I had never worked in, I'd done global health work, but had never worked in domestic public health, and so I did it really to kind of explore that path and understand like, is this maybe a better fit for me in my career?

Q: Okay. Well that takes you up to when you start the EIS program in July 2020, correct?

MILLER: Yes.

Q: Yes! Tell me about that. Tell me, so how did you transition from working as a physician in Boston to this EIS program?

MILLER: Well I guess by July I knew where I was placed for EIS, so I knew that we'd be moving to Seattle, so you know, we packed up our life in Boston, sold our--my partner and I were living in a condo at the time, sold the condo, put our stuff in a bunch of those like, you know those U-boxes, those like, plywood or whatever boxes that you can rent a couple of, put all your stuff in, and then they put them on a truck and send them across the country? We packed up all our stuff, kind of left Boston, at that point I went to Atlanta, because we had our 00:23:00initial training in Atlanta, and spent a few weeks there. It was kind of this funny kind of hybrid world where we were in Atlanta, but most of the stuff we were--because of COVID most of the training was virtual, although we had to be at CDC headquarters for some of the things, some of the more sort of administrative things and medical clearance, and fit testing and those kind of things. So yes, spent a few weeks in Atlanta, and then got on a plane again and landed in Seattle.

Q: Tell me more about your time in Atlanta and this early training. Can you be a little bit more descriptive about what you guys were doing?

MILLER: Sure! So, there was kind of the administrative parts of becoming a new CDC employee, but then I think the main focus is like, a crash course in epidemiology and public health. Because folks are coming from lots of different 00:24:00backgrounds. Some folks have just finished a PhD in epidemiology, some of us were physicians, some of us were nurses, veterinarians, PhDs in other fields. People were coming in with lots of different backgrounds, and I think most people have had some exposure to public health and epidemiology along the way, but the idea is kind of get everyone on the same page and kind of a refresher for me I had done an MPH [Master of Public Health], but that was probably I guess almost a decade before EIS, so some of those things were kind of rusty by that point. So it was mostly kind of a mix of like, lectures and discussion groups where we learned about an epidemiological concept and then do some kind of like, group exercise to kind of practice those topics, or those concepts.

Q: Yes. How did you come to go to the Washington State Department of Health? For 00:25:00your EIS officer training.

MILLER: There's a match process in the spring, which in non-COVID times would have been in person at the annual EIS conference. For my group, because of COVID, it was all a virtual process. You have a chance to meet with current officers and supervisors for different positions, learn about different positions and then sort of decide what you think is the best, would be a good fit for you. And so-- I think I was sort of interested in some of the global health positions, and I think also interested in some of the field positions, like the one I'm in right now, and I think partly because of COVID, felt like maybe it made more sense to be in a field position and really sort of be part of the domestic COVID response. But that was part of it, and I think also just connected with the supervisors for this position and seemed like a good-- it 00:26:00would be a good mutual fit, so between those things, decided to try to be in Seattle, and I was fortunate that that worked out for me.

Q: Great. All right. Tell me about the Washington State Department of Health. Can you be, like how big is it, when you came in at the time, was everyone remote working? Kind of like the details. Like when you came in, what did you see?

MILLER: Sure. The Washington State Department of Health, the main department of health is in Olympia, which because of COVID, I've actually never been to the main office. My office is based at the public health lab, which is in Shoreline, which is just north of Seattle. When I first arrived, it was kind of a hybrid, like some people were working remote, some people were in person. I was in the 00:27:00office a fair amount of the time for the first few months, I guess. Then, when the, I think it was when the Alpha surge first happened, kind of fall/winter of 2020, I'm trying to keep my months and years straight here, yes I think fall/winter 2020, then we got the message like everybody who can reasonably work remotely should work remotely. My colleagues who work in the public health lab like actually doing, benchwork in the lab, they were still going in, in person, because there was no other way to do that work, but pretty much all of the epi staff at that point were asked to work remotely.

The public health lab is mainly a working laboratory and they do COVID testing, and COVID sequencing, and they also do all of the other things that a public health lab does--they have the bioterrorism lab, they, I think there's newborn screening there, they do the like shellfish and environmental sampling. They do 00:28:00the other testing for notifiable diseases, sort of the specialized things that aren't necessarily done in hospital labs. All those things had to carry on amidst COVID as well. Then the communicable disease epi group is based there because, partly because we interface with the lab, but it's probably is a fairly small group of, within that facility, and then I think, I don't remember the exact timeline of this, but the department of health also set up kind of like a COVID-focused office, in addition to the regular communicable disease epi group. A lot of the communicable disease epi folks were working on COVID at that point, and then they also set up an additional COVID office, just because there was so much work to be done on COVID, and hiring a lot of new staff.

Q: You were in the office until December 2020, kind of?

MILLER: Yes, maybe November? I think it was like around Thanksgiving, but I don't remember exactly.

Q: Wow. That's quite different from most people who had been teleworking since like, March, so.

MILLER: Yes. But I guess it was kind of, I think it was kind of a hybrid, some folks were teleworking then, and some folks were in the office. I'd been going into the office partly because I was new, and it was helpful to be able to just wander down the hall and talk to my supervisor and be like, how about I do this, or what do you think about this? So I was glad that I had that opportunity for a little while.

Q: Yes. How did you fit in with the department? What was your role within this massive state health department?

MILLER: Yes, so I guess from sort of a, I guess like an organizational 00:30:00standpoint? My primary supervisor is the state epidemiologist for communicable diseases.

Washington is sort of unusual in that there are two state epidemiologists. He's been very involved in the COVID response really from day one, when you know, that first patient was identified in Washington.

Q: Who is it? Do you mind giving me his name?

MILLER: Oh sure, Scott Lindquist.

Q: Okay.

MILLER: L-I-N-D-Q-U-I-S-T. Scott like the way you'd expect it. I mean so I think from a learning standpoint, that's been really helpful for me, because he's involved in a lot of different aspects of the COVID response, and I think he's tried to balance the needs of the response but also the goal of having this be a learning experience, and kind of getting broader exposure, so I've worked, I 00:31:00kind of worked on a number of different parts of the COVID response over time. Partly as the response evolved, and I think also as essentially a trainee for the purpose of having that exposure to different parts of the work.

Q: What is Washington State's connection to the rest of the public health community? How does it kind of like, fit in there? I guess this is like a little bit more of a broader question. Yes.

MILLER: Sure. Yes, so, and like let me know if this isn't kind of what you're getting at, but Washington is what's called a-- what people often call a home rule state. The primary public health authority rests at the local level. There are local health jurisdictions across Washington, usually at the county level, although sometimes there are some health districts that combine two counties. They would have primary public health authority for most things. Then the state 00:32:00department of health, I think, functions as kind of a coordinating body and it provides support to local health jurisdictions. Then of course the state department of health would have connections to CDC. I think another thing that we've seen in the COVID response that I think has been one of the, I think the positive things is you kind of realize the way that public health connects to other agencies outside of the public health system, so we've collaborated a lot with state labor and industries, because of the impact of workplaces and COVID. We've collaborated a lot with correctional groups, so there's like the State Department of Corrections, and then I've worked a lot with the Washington Association of Police Chiefs and Sheriffs, which is kind of like a coordinating body for the jails across the states. I'm trying to think what else. 00:33:00Partnerships with universities, particularly the University of Washington, and I think that's been, so I think that's been a positive thing about the COVID response is that it's, I'm sure some of these partnerships and relationships were there before COVID, but I think COVID has helped, by necessity has helped with strengthening those partnerships outside of the kind of formal public health system.

Q: Yes. Sure. Let's talk a little bit more about these partnerships. Let's talk about your, I mean let's just start with your EIS work that you've done within the response. What was kind of like your first thing that you were doing when you got to Washington State? How did these partnerships kind of impact your work overall? I know they impact the work probably more in some of your work than others, but like let's just start with the beginning.

MILLER: Sure. The first project I worked on was an analysis of contact tracing 00:34:00data. This was still relatively early on in the pandemic, and Washington, in the kind of spring and early summer, had set up a state-based contact tracing system. There were also contact tracing systems at the local level, the state was doing contact tracing for some of the local health jurisdictions, either all of the contact tracing, or as kind of overflow capacity. I think what we were trying to do was understand like, how well is the system working? It wasn't like super fancy data analysis, relatively simple questions, like what are the different stages of the process of getting from someone developing symptoms or getting tested for some other reason, getting tested, getting the results of that test, that result getting into the, getting reported to the Department of Health, and then that case being, or that person being assigned to an 00:35:00investigator, the investigator calling the person, hopefully getting in touch with them, maybe having to call them multiple times, interviewing them, getting information about their contacts, then calling the contacts.

There's a lot of different steps in that process. We were trying to understand partly, how long each one of those [steps] take, because I think by that we understood that like in order for contact tracing to be effective, it has to happen as quickly as possible. How long does each step take, is there opportunity to shorten any of those steps or reduce a delay? Then I think the other piece of it was like, where does the, I don't know if attrition is the right word, but where do people kind of fall out of the system? Is it that when you call people they don't answer the phone, and you never manage to talk to them? Or you talk to them, but you know, they're not willing to be interviewed? Or they start an interview but then they're, for any range of reasons, they're 00:36:00reluctant to report their contacts, or their contacts don't answer the phone? Where are sort of the gaps in the process, or where are people falling out of the process, and not able to complete the investigation, or notify their contacts?

Q: I know for a lot of, this has kind of been a hot topic, of the COVID responses for a number of local public health responses. But the capacity to manage all of this data for the databases, it just had to be really, they were almost working on an antiquated system. Excuse me, I just butchered that word really bad. (laughs) Did you find that same kind of issue there? Were you, did you have like, any kind of like, I guess like data processing issues, or computer issues, or anything like that?

MILLER: Yes I wasn't, I didn't work directly on that piece of it, but from the 00:37:00piece I did experience, I think Washington started off with a, I think initially no one knew how big this was going to get, like in the spring of 2020, so they started off with a REDCap-based system, REDCap [Research Electronic Data Capture] is kind of like an online data entry and data management system, which has the benefit of being quite flexible and pretty easy to stand up quickly. I think, so that was the system when I had started, and then around sometime in the summer of 2020, they realized that the amount of data and the volume of contact tracing was just too much for that, for the REDCap setup they had, and so they ended up switching to a different data system.

I think that's also been an issue for, there's like, contact tracing data, and 00:38:00then there's COVID test result data, and I think Washington has also really experienced that with COVID test result data. Because the state is supposed to get all test results, whether positive or negative, and that, the initial, the reportable disease data system was kind of set up for diseases that are comparatively rare. Like we don't get that many measles cases reported, we don't get that many TB [tuberculosis] cases reported, or you know, any of the other reportable diseases. It was set up for, it wasn't necessarily set up for a super high volume of tests. Again, I don't work on this directly, but I think they've experienced a lot of challenges just with the volume of data coming in, and not being able to process it using the current system, so they've had to like, divert negative tests out of the system to preserve room for positive tests, as 00:39:00they've tried to modify the systems, you have more capacity.

Q: Yes. Did that not affect the contact tracing work that you were doing? Like you know, the system not being set up for this volume of cases to, I mean to track the positive and negative cases, did it affect it at all, or? Certainly they work hand in hand, right?

MILLER: Yes, I don't think it affected it too directly, in the sense that they were able to divert the negative results, and so the ones that we were going to do contact tracing for were the positive results, so those continued to flow into the system. I guess that the time that I was working on this was pretty early on, and so it was still using the original REDCap-based system. I can't speak as much to the more recent experience of the contact tracing data system, because the time when I was most involved was that sort of summer 2020.

Q: Yes. What did you find? Like, looking for these kind of gaps in the system and just evaluating it, how effective was it, you know? What were the gaps?

MILLER: Yes, so, and I guess to sort of set the stage for that, initially I started working with one of the local health jurisdictions, and then expanded to a few others in central Washington.

Q: Which health jurisdiction if I can ask?

MILLER: Oh sure, initially it was Chelan-Douglas health district.

Q: Okay, got you. Thank you.

MILLER: Yes. One of the features of the epidemic there at the time was that Hispanic communities were disproportionately affected, and so I think they were concerned about, is the contact tracing system, partly is it working for everyone, but particularly is it reaching Hispanic community members who were 00:41:00disproportionately getting COVID at the time? We had kind of gone into it with, I think, that lens or that concern of like maybe, especially because it's a phone-based thing as opposed to in-person, and so not like traditional contact tracing in the past, which might have been done in person, is it going to be harder to make that connection and are people going to be reluctant to give their information to the government, essentially? Especially for community members either who themselves might be undocumented, or you know, who might have friends or family members who are undocumented, are they going to feel uncomfortable giving their information to the government? I think we had gone into it with that lens of like, trying to understand is, how well is the program reaching different groups across race, ethnicity, age? I think we were also 00:42:00wondering like, is it going to be hard to reach younger people, or older people, using this system?

What we found is that the system was across, at least based on the available data we had, and I think we didn't have maybe the kind of granularity you would ideally want to answer those kind of questions, based on the available data of age, race, ethnicity, it didn't appear that there were any substantial differences in, or across counties, for that matter, in how well the system is reaching people. But one thing we did see is that overall and across all of these groups, people seem to be reluctant to name their contacts, most people said that they didn't have any contacts. For some people, that might have been true, but I think for most people, that probably didn't reflect their actual 00:43:00life, and that, partly just in the sense that most people live with someone, so they at least have the contacts within their household. I think the data we had didn't really allow us to understand why that is. There are a lot of potential reasons you could imagine, and those reasons might differ for different people, or different groups.

But I think that was one of the surprising findings for us, is that we had expected that maybe some people wouldn't reachable by the system, or that just nobody would be answering the phone, because in 2020 we all get lots of spam calls on our cell phones, and you see a number you don't recognize, or especially you see a number from a different area code, because you know, calling from like Seattle or Olympia area, and you just don't even pick up the phone. I think we had kind of gone in with that expectation, and what we found is that actually like, that was an issue, some people didn't answer the phone, but the majority of people, they were able to reach them, but then most people 00:44:00said we don't have any contacts.

Q: Yes. Why were they so reluctant to, I mean did you, were you able to find why they were so reluctant? Or just kind of just knew they were?

MILLER: Yes. Yes this is all kind of supposition I guess, based on the data that we had. Because we were using the data from the contact tracing system itself, we weren't like, going out and interviewing people who'd had COVID, and trying to--and so I think because of that, we didn't really, we weren't able to capture that nuance of individual experiences. We could tell that people had either answered the phone or not answered the phone, or we could tell if they had either reported contacts or said that they didn't have any contacts. But we didn't have information about why that was. Anyways, one of the, I mean this is a challenge with a lot of work like this, that the people who didn't answer the 00:45:00phone, we didn't really have any information about them at all, because they weren't interviewed.

It's hard to say anything about that group. Then even for the group who were interviewed but didn't name any contacts, we didn't have any way to figure out whether they actually had contacts and didn't want to report them, or they didn't have any contacts, and if they didn't want to report them, then what was motivating that concern?

Q: Yes. All right, well after your contact tracing work, what did you--I mean I know it's kind of like, once you were done with that, you went onto this next project, but (laughs) so what then happened after your contact tracing work? You're working on that, was there other things happening concurrently that you were working on? What other projects were you on?

MILLER: I think right after that, I worked with a-- there was a CDC team that 00:46:00was deployed to central Washington, again to Chelan-Douglas, the same district that I worked on the contact tracing data for, to try to understand the clear disparity there in, as you know, why, the Hispanic communities make up a substantial minority of the population of that county, but a minority, and represented a majority of the COVID cases in that, in those counties. I think the local health district was trying to understand like, what's driving this, and how can we help solve this? There was a CDC team that came out to help look into that, so I worked, at least spent part of my time working with that team for a few weeks.

Q: Yes. I guess that brings up questions about like, health equity. I mean, what was considered within the response to either increase health equity or, what 00:47:00were the health inequities faced by this Hispanic community?

MILLER: Yes. I think it's probably--well I guess first I'll say that I think it's, I think based on a few weeks, it's probably hard to have a full picture of that. But, I think from at least the work that we did, and experience I had, I think it's a lot of different things. I think some of it is workplace exposure, so I don't know that we, I don't know that we had super--well I guess actually we did have survey data documenting this, that Hispanic community members are much more likely to work in-person, and much more likely to work in agriculture, and so I think folks were more likely to be working in group settings in-person. 00:48:00That's probably one piece driving a higher risk of infection. I think probably housing plays into that too, you have, Hispanic community members are more likely to be living in larger households, and so you have--and if one person in the household gets it, then obviously everybody else in the household has a fairly high risk of getting infected as well. Then, and I think those two things probably kind of magnify each other in a certain sense, in that you have a larger household size, and so you might have multiple essential workers in the same household who are all working in person, and so that household has multiple people who are potentially exposed at work. And then of course, and I'm sure there are some people who are getting infected just in their day to day lives in the community as well. But I think probably the biggest, I think my sense is 00:49:00that the biggest factors in driving that difference were probably the household structures and workplace structures.

Then I mean, there's the sort of, a whole range of things that might have less direct impact, so it might still impact people's risks. You have access to healthcare, historical experience of racism, or current experience of racism, you have immigration status, and people's willingness to access services based on concerns about their own immigration status, or immigration status of their friends, or family members. Access to information based on language skills and literacy. I think there's probably a much broader set of determinants that we might not quite just have, be able to point to it directly, like that person got infected at work, and then they infected their household. But that also may 00:50:00impact people's ability to take prevention measures, to access information, to access care, to access testing, all of those kind of things.

Q: Yes. What was done with the Hispanic community there? I mean, were there people on the team that spoke Spanish with you, or yes, so what, how did you guys reach and coordinate with this community?

MILLER: Yes, so I think there were a couple different goals for that deployment. The rest of the team, apart from myself, all were bilingual. They had intentionally chosen the team to have, for people to have that skillset. I think one element was to understand, to try to understand the epidemiologic data a little bit more, in terms of both the COVID testing data, but also hospitalization data, but I actually think that was probably the least important part of it. I think another piece was to connect with community leaders, 00:51:00community groups, and community members through sort of meetings, and focus groups, and to understand what they thought was going on, they had a much, much more experience in this community, and direct experience of these inequities. I think that was probably the most valuable part of the work in the deployment. Then the third piece was a, conducting a rapid--it's called CASPER [Community Assessment for Public Health Emergency Response] survey, basically like to understand community perspectives, and needs, and behaviors around COVID. They conducted it over a couple, I guess like maybe a two-week period conducted a fairly rapid survey in that community, so those were probably kind of the three main pieces, but I think the most important one was really connecting with 00:52:00community groups and community leaders to understand what they thought was going on, and how they thought it could be solved.

Q: What did they think was going on? What came out of those partnerships?

MILLER: Yes, I mean I think some of that is what I had just shared about like understanding the, how many people in those communities were essential workers and had to continue working in-person. I think some of the nuance of that is around time periods too, that this was in the kind of late summer, early fall. Just, and that area is pretty agricultural, particularly tree fruit, like apple, pears, those kind of things. That was kind of like the height of the harvest season, and so it was a time when people were--partly like the, most people, 00:53:00the most, the highest number of people would be in those workplaces at that time, there was a real need to work, because folks probably earned a good chunk of their money for the year, or at least some people earned a good chunk of their money for the year during that period. I think understanding just like kind of the nuances of the, of work in that setting, what that meant, and the need to continue working in person, and then I think also sort of understanding--and we had data on this from the survey, but I think understanding how that plays out in a household as well, people are more likely to be in a larger household, and also to have, if someone does get sick, to not have as much space to isolate. I think those conversations and those 00:54:00relationships helped to kind of understand what the survey data actually meant.

Q: Okay. All right, well what was your role in this study? We've kind of talked about what the study did in general, and you know, what the two teams were doing, what were you doing in the study?

MILLER: Yes, I mean I guess I would say it wasn't really a study per se, it was more of a-- kind of a community-focused deployment.

Q: Okay.

MILLER: But I worked on a few different pieces of it, I was working on some of the epidemiologic data, looking at the data that some of the local hospitals had shared, and then also helping some with the survey.

Q: When you say like, looking at the epidemiological data, can you explain a little bit more about like, what that means, like what were you doing 00:55:00specifically, I guess?

For someone who has like--

MILLER: Sure!

Q: --you know, no knowledge of what this could be, you know?

MILLER: Yes, we had a few different data sources, one was COVID testing data, which the local health jurisdiction already had and had looked at. Then, the local hospitals also shared information about the data that they had about who was getting care, and who was getting admitted, those kind of things. Those were the two main data sources, but you know, as I had mentioned, I think overall the local health jurisdiction already had a pretty good understanding of the epidemiological data, so I don't, I think in my mind, that was sort of the least important part of what we did, because I think they already had a good understanding of that, and they knew that this disparity existed already.

Q: Okay. All right. After you're working with this community-based deployment, 00:56:00what else happened? Like, I guess what happens next? What else happens? What happens next?

MILLER: Yes. I guess in the fall and winter of 2020, and sort of starting into 2021, this coincided with the Alpha surge. With that, we had a bunch of, unfortunately, a bunch of very large outbreaks in state prisons in Washington, and also in jails. That was sort of when I first started working closely with correctional partners in Washington, most closely with the State Department of Corrections.

Q: Yes, so this is one of those partnerships you were talking about? Yes. Do you 00:57:00mind explaining more about like, what were you doing, like what was your role during these investigations? I'm sure that's not the correct term. (laughs) But yes, what was your role?

MILLER: Sure. I mean, I think just to kind of like, again to kind of provide the context, this is probably somewhat obvious, but prisons and jails are a really challenging setting, in terms of transmission of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] and preventing outbreaks, because you have, it's such a congregate setting, you have so many people sharing the same space, sleeping in the same areas, eating in the same areas, and these facilities are often old and weren't really--and certainly weren't constructed with anything like COVID in mind, so you have some facilities where you have like, bars between different cells, or different units, but of course bars aren't going to 00:58:00stop airflow. So just a setting where SARS-CoV-2 can spread very quickly, and you know, it's challenging to control. My work, or one of--and I think one of the things we identified, our partners at the Department of Corrections early on, is that staff were a key source of introducing infections into the facility, because of course staff go into the community, and back to the facility every night. But once COVID gets into the facility, it spreads rapidly. Or once SARS-CoV-2 gets in, it spreads rapidly.

But if we wanted to try to keep it from getting started in the first place, then one of the key interventions was to focus on staff. Of course, masks are a part 00:59:00of that, but the other piece that we worked on setting up, I guess this was kind of probably, I can't remember if it was late summer or early fall, but around that time, 2020, was serial testing of all staff who would have contact with incarcerated people. Basically every staff member who would be in contact with incarcerated people would get tested every week. I think in an ideal world maybe it would have even been more frequent with that, but there's of course, that's--it's a big logistical operation, and so I started off working, helping to kind of train the Department of Corrections staff on PPE, and specimen collection, and how to operationalize this weekly testing of all of the staff. I think the other piece of it was working with the Corrections leadership, both 01:00:00primarily sort of their medical and public health leadership, but also on the custody side, to think about what are the right mitigation measures or prevention measures to put in place to prevent transmission.

Thinking about, of course the testing of the staff, testing within the incarcerated population, how to limit the potential for facility-wide spread by having cohorting, how to limit introduction into the facility by having like, intake testing and we called it like intake separation or intake quarantine, where people who were coming into prison are housed separately, because they might have COVID when they're coming in, so housed separately until they can be tested multiple times and make sure they don't have COVID before joining the general population. Transfer testing and transfer separations, the same thing 01:01:00when people are being transferred between facilities. Then of course, like isolation and quarantine planning. I think there's also an element of, even there are different types of facilities within the correctional system, and so people kind of sometimes think of it as like a, there are just prisons. But there are substantially different built environments, depending on the custody level, or security level of a prison. And so that implies different measures. There are also work release facilities, where people are still, I guess, in custody, and still living at a Department of Corrections facility, but going into the community every day for work as part of like kind of a reintegration into society, and so that people have a job when they are released. So there's kind of different measures for different facilities, depending on the structure 01:02:00and resources at that facility.

Q: Okay. Yes. What was like, the outcome? Like after teaching the correctional facility leadership and everything, like all of these measures that they could take, did it actually improve COVID-19, the COVID-19 situation in the prisons? What kind of happened? After doing all of this?

MILLER: Yes, it's a good question, I don't know that we have sort of a rigorous way of evaluating the impact of any one intervention, or even sort of a package of interventions. Part of the challenge too is that the virus has changed over time, and consistently (unclear) has become more contagious and harder to slow 01:03:00transmission over time. I do think that the, the sort of combined set of protective measures had a substantial effect. I think one of the lessons in my mind from these kind of settings is that no one of these measures is perfect. If you look at any like, individual measure, you'd be like, that's not going to work. Testing staff once a week, you're like well, that's going to catch like, some of the infected staff and prevent some like, contagious days inside of prisons, but like, plenty of folks are going to slip through, and they're going to be contagious for a few days before they get tested. And so, like it's not really going to work. Probably not.

Same thing with each of the other measures, again, like you know, none of these are perfect, and so I think of it kind of like the, there's this thing you may 01:04:00have heard of called the Swiss Cheese model of medical errors, where, which is--medical errors are a different concept, but the idea being that errors happen when there are like, multiple breakdowns in a system, and sort of if you imagine like, a couple different slices of Swiss cheese that most of the time, if you put, each slice has holes in it, but if you put three slices together, the holes don't line up.

Q: Yes.

MILLER: But what happens when the holes line up, that's when something slips through, that's when an error happens. I think of the COVID precautions, particularly in these kind of settings, kind of like that, that any single measure has a bunch of holes in it. But the idea is to layer enough measures together that the holes don't line up, and you can prevent transmission. It certainly hasn't been, by any extent, like perfectly effective, and we had, 01:05:00unfortunately had huge outbreaks again during this most recent Omicron wave.

Despite like having those measures in place, and I think we thought having learned a lot over the last year and a half to I guess two years. So, it certainly hasn't been perfectly effective, but I think that that's sort of the takeaway that I've had is that you have to, you have to put a bunch of measures in place, and each one will be partially effective, and hopefully they add up to substantially reduced transmission even if they don't stop outbreaks, or stop transmission entirely.

Q: Did you go on any deployments during this time, or during your time as an EIS officer?

MILLER: Not in sort of the early vaccine period, I think I was still kind of 01:06:00working in corrections in Washington then. I think there was a lot of work around the roll out of vaccines, and how that was going to play out. I think that the next deployment I went on was in the late, yes it would have been late spring 2021, I think it was in May. That was a CDC deployment to Texas as part of the southwest border response. My specific role, there was a large number of unaccompanied children who had arrived in the U.S. The, I guess it's the Office of Refugee Resettlement has the responsibility for caring for those children and reuniting them with family members. They were setting up these what they called 01:07:00emergency intake sites for children to stay at while they were in the process of being reunited with the family. There were CDC, I guess, advisors essentially, at each of the facilities to help with COVID prevention, and COVID outbreak response, and also other infectious diseases that might come up in that setting, things like chickenpox, lice, scabies, I think we had a hepatitis A case at one of the facilities where I was based. A lot of it was COVID, but also other infectious diseases.

Q: Yes. You were one of the CDC advisors there? Yes, tell me a little bit about like your role, like what were you doing day to day, and how long did you, how long were you deployed for?

MILLER: I was there for three or four weeks, I think. Day to day, it felt like a lot of different things. I think one piece of it was working with the facility, and the medical contractor for the facility on the COVID prevention and COVID response measures.

That meant the testing approach, I think that was kind of like the, in some ways the backbone of it, the approach that we took was that everybody in the facility, staff and children, got tested every three days. The idea of course being to identify people quickly so that they, there was less time for them to transmit to others. Making sure that that was going smoothly, that everyone was 01:09:00actually getting tested every three days was one piece of it, tracking the resulting data from that. One piece of it was infection control, so you know, that sort of general like, masking throughout the facility, and then also specifically isolation and quarantine protocols, often in settings where like there wasn't, they hadn't been built to accommodate that. One of the sites was at like a, I think it was like a coliseum or, I actually can't remember what the name of it was, I think it was called the Coliseum, but basically like an event venue, and the other one was at a military base, and so they, neither of those were set up with the goal of like, how do we isolate or quarantine people with a contagious disease? Trying to figure out, based on the space you had, and sometimes that was like these big tents that they had set up, how best to use 01:10:00the available space to separate out folks who were confirmed positive, folks who were over, like probable positive based on a rapid antigen test, folks who were, if we had the ability to quarantine the folks who were exposed but had tested negative so far. And then also, staff safety, making sure people were wearing PPE appropriately in those settings, and had appropriate training and protocols for that.

Q: Tell me, like were there like, any issues that you kind of faced? Like you know, were there any kind of like, spectacular moments, I guess? Kind of like fill it out a little bit more than just the description.

MILLER: Sure. I mean I think lots of issues, these facilities were being set up 01:11:00rapidly, and I think people were doing their best, but things were just inevitably kind of a bit chaotic. I think from a COVID standpoint, I was, in some ways, was surprised at how well the measures worked, and how well you could control transmission in those settings. That kind of goes back to the Swiss cheese part that we were talking about, that is, coming in, you kind of look at it and you're like, the bigger facility there was, it was basically an event space, and so it's just hundreds and hundreds of children sleeping in this big room, a huge like exhibition hall kind of room. We didn't really have the ability to do like, contact tracing or quarantine, so people would get tested every three days, people who'd, if children tested positive, they would go to 01:12:00isolation, and then everybody else would just stay in their pod within the facility.

But it's not like the pods were, had separate space or separate airflow, it's just like there were cots for a pod and then six or ten feet away, the cots for the next pod started. So, I think coming in it was like man, like it's great that we're testing every three days, like, but is this really going to work? Because by the time you identify a kid who's infected, they've probably infected someone else before you can identify that, that they're positive, and move them to isolation. But so, I think I was surprised at how well it worked, just by layering different measures, that the testing isn't perfect, but it's, it probably carries a good chunk of the load, and then masking, and then trying to 01:13:00do things outdoors whenever you can, and you know, the various other measures that we put in place. I think one of the sort of memorable parts for me was when we had this hepatitis A case.

I guess for, just to sort of provide background you know, hepatitis A is like, a very contagious disease, normally spread through the fecal oral route. It can be spread by sharing food, lack of hand washing, people who like are sharing a bathroom, or cleaning bathrooms, can be infected. I remember when we got that lab result back just being like, oh no. In the end, we didn't identify any further transmission, and we were able to, one of the interventions you do is you do like, post-exposure vaccination for people who are potentially exposed, 01:14:00and so we were able to do that reasonably well, I think that was the biggest challenge though was because we realized that the cohorting was intended primarily for COVID, but there hadn't been any cohorting for the bathrooms. So we were like well-- like anybody could have been exposed in the bathrooms. Likewise, any of the workers who clean the bathrooms could have been exposed, because we didn't know like, which bathrooms this person had used, or who would have cleaned those bathrooms. We had to come up with like, who do we think is potentially exposed, and who do we do post-exposure vaccination for?

As far as we know, no one else was infected, but I think it was one of those moments when you're like oh man, is this going to get really bad? Like, I wish 01:15:00that, we were focused on COVID, but I wish that we had, like you know, you wish in retrospect that you had like, cohorted the bathrooms as well so you'd have a better sense of who was potentially exposed.

Q: Yes. Were there any other, so after you were deployed, so you come back to Seattle, so what did you work on next?

MILLER: I think basically right after I got back, that was when there was this, the potential, what at the time was the potential association between COVID vaccines and myocarditis or pericarditis had been identified. I think pretty much as soon as I got back, I sort of jumped into working on the investigation that the Department of Health and Public Health Seattle King County were doing, 01:16:00looking into people who'd developed myocarditis or pericarditis potentially associated with COVID vaccination.

Q: Yes, so kind of walk me through the steps of that. What was your role in it? What were you doing?

MILLER: Yes, so my, so there were kind of two parallel investigations. One was more of a clinical investigation, and then one was a bit more of kind of an epi study. The epi side, which I was less involved with, they were using syndromic surveillance data, to try to understand how much of an association there actually was. Basically, looking at, comparing people who presented to an emergency room for myocarditis or pericarditis, and then looking at people who had presented with injuries, since we presumed that the risk of those [injuries] 01:17:00wouldn't be affected by COVID vaccination. Looking at like, how likely were those different groups to have received a COVID vaccine recently. Basically, to try to understand like is there a true temporal association here?

Then the other piece was, we put out an alert asking clinicians to report cases of myocarditis or pericarditis potentially associated with vaccination, and then were doing investigation looking at the clinical records from those individuals to try to understand more of the clinical--

Q: How did you alert the physicians? I'm sorry, I didn't mean to interrupt, how did you alert physicians? --yeah.

MILLER: Oh sure. Yes. I guess a few different ways, there was like a health alert network communication that went out to health facilities, we also, we asked local health jurisdictions to reach out to health facilities in their 01:18:00area. I think you know, there was also at that point more and more news coverage of this, and so that probably helped as well, we weren't directly responsible for that.

But probably those three things. And so then we started getting these reports coming in from hospitals or from individual clinicians of cases of myocarditis or pericarditis, and you know, particularly for myocarditis, and pericarditis, I guess, there's a wide clinical spectrum there, you can have very mild cases, and you can have severe cases requiring a heart transplant, or potentially fatal. We wanted to understand more of like, what are we actually dealing with here? What's the clinical syndrome? We partly worked with also some colleagues from CDC to figure out like what information do we want to capture from each of these 01:19:00medical charts? Then myself and a number of other clinicians would review each chart to try to sort of extract out that information and understand what had happened to that patient. I think the other piece we were trying to understand is, which of these cases are potentially associated with the vaccine, and which ones have like, a pretty clear other cause. Someone who had a clear, one of the things that can cause myocarditis, for instance, is a viral infection, and so people who had just had COVID, or just had another viral infection, we would say like well, that like, could have been associated with the vaccine but it's probably more likely it was associated with the infection they just had. Trying to figure out, or some people who had like a significant autoimmune condition and maybe that explained their myocarditis.

These are just examples, but basically the larger goal was understanding which 01:20:00of these cases do we not really have an alternate explanation for, and therefore, it's more likely to be related to the vaccination, and which of these cases do we have another compelling cause for the myocarditis or pericarditis?

Q: Yes. Was there a lot of reports coming in at the time, or was it few and far between?

MILLER: I guess a fair number, I mean I think this is still, these are not common diseases in general, and it's not, as we understand it now, it's a very rare side effect after vaccination, so it's not, it wasn't exactly like we were getting thousands and thousands of cases. But it was a somewhat labor-intensive process because you had to contact the health facility and get the records, and then you know, read through all of the notes, and lab values, and imaging 01:21:00reports, and all of that and enter it into our data form. Yes, each one was a decent amount of work, but yes, it wasn't like we were getting thousands and thousands, it was still, it's a pretty rare thing.

Q: Yes. How was the data used? When you're finding out all the stuff about the myocarditis, whether or not it's connected to the vaccines, and you know, how it's most likely connected to these other diseases. How is this data being used?

MILLER: Yes. I mean I think the overarching goal is to understand a couple of things, like what is, how large is the risk? Is it associated with particular vaccines? Is it associated with particular groups of people? And then how severe is the illness? Does this change anything about our recommendation for vaccination? I think our work probably played a small part in that. Of course, 01:22:00many other folks, CDC and many other researchers across the country were looking into this as well. I think it was sort of, in some ways, remarkable how quickly this went from being something that was like huh, what is this, is this maybe an association? To something that we actually had a fair amount of information on.

I think the takeaways again from our work, but also from the work of many others, were that this was more of an association with the mRNA vaccines, most likely to occur in young men, although of course rare throughout, but most likely to occur in young men. And that most people had a, I don't know if I should say mild, but a relatively mild disease course, so you know, the majority of people would not be hospitalized, or might be hospitalized briefly, but 01:23:00wouldn't go on to develop heart failure or a more critical illness or other significant complications.

Q: Yes. Were you worried, like because the COVID-19 vaccines were such, I mean politicized, were you worried that these reports of myocarditis would hurt the vaccines' I guess image even more, to where it might affect intake, or was that even something that was on your radar, or--?

MILLER: Yes, I think that was definitely a concern, and I think that the primary reason to investigate is to understand the health complications, but I think that's another reason to investigate is like, we have to understand the risk and be transparent about that, and then figure out like, does this impact our 01:24:00recommendations for vaccination? Because it was such a rare thing, and also frankly, because getting COVID can also cause myocarditis, or pericarditis, that it ended up being not really a close call. Vaccination still makes sense. But I think that was another, that you know, public trust is another important reason to investigate, and to communicate the results of that.

Q: Yes. Of course. Yes. That brings you up to like, the summer of 2021. Then you have the new Delta variant that comes along. Yes, do you want to tell me more about your work as it's going on, and all these, how it connects to these kind of bigger, like a bigger picture going on in the pandemic with the new variant, 01:25:00and the COVID-19 vaccine rollout, and all that other kind of stuff.

MILLER: Sure. Yes, I mean I think for all of us working on the COVID response, that you know, variants of concern has been another kind of theme running throughout this, that each time there's this rush to try to figure out what do we know about this new variant, what can we understand initially? I think there is, looking back it's like oh there's this obvious kind of succession of variants. But at the time, like we didn't necessarily, especially I guess prior to Delta, we didn't necessarily know which variant was going to take off, so there was like, Alpha has sort of started to outcompete others, but then there was also, sorry, P.1 circulating, and particularly in Canada, which, obviously 01:26:00bordering Washington, so we were kind of wondering like what is going to be the next big thing? Then of course, Delta happened, and then Omicron. I think each time there's been this kind of-- this effort at the Department of Health, and of course CDC and local public health to understand the rapidly evolving information about that new variant, and you know, some of which turns out to be true, and some of which turns out to be maybe not accurate as more data becomes available.

I think it's, I think, I mean you know, sequencing has been a part of public health for a while, for food-borne investigations, for you know, HIV cluster investigations and other things for a while, but I think COVID has been also a 01:27:00place where sequencing has really kind of taken center stage and become much more in the public eye as well. I think that's another, I guess in some sense a positive thing that's come out of COVID, that you're really sort of accelerating the use of whole genome sequencing for public health, both from the sense of understanding what variants are circulating at a given time, and how is that changing over time? Although I think it also has, there are other I think interesting and exciting potential--not even potential, actual uses of it, especially as we think about outbreaks--traditionally like EIS officers, would--you would investigate outbreaks and try to understand what was associated 01:28:00with what, and using kind of traditional epi methods. I think this is an exciting way to say like oh, well okay, we can sequence these cases and understand that this group and this group are pretty far apart genetically, so those are actually not the same outbreak.

Or you know, this group is, these cases are all pretty close genetically, and so those are at least, it doesn't necessarily prove that they're part of the same outbreak, but at least compatible with being part of the same outbreak. I think that's been one of--the kind of the exciting developments that COVID has really spurred in public health. Here in Washington, we've had a fair amount of collaboration with the University of Washington, which has been a real leader around COVID sequencing, and so I think I've felt fortunate to learn a lot from those folks, as well.

Q: Yes. How is this really like, impacting your work? The sequencing for example, how is it, you said that it has been like a fruitful collaboration, how so?

MILLER: Yes, I mean I think it's for a range of things. I think again, probably the most immediate one is kind of a surveillance function of understanding what's the mix of current variants, and how is that changing over time? Watching the Delta rapidly displace other variants, or Omicron rapidly displace other variants. I think another angle that I hadn't mentioned was understanding variant severity. This has obviously been in the news a lot with Omicron, although I think potentially overblown in some ways. But you know, trying to understand the relative severity, which you know, the original variant compared to the Delta variant, which I think, both in Washington data and elsewhere appeared to be a substantially higher risk of severe illness compared to the 01:30:00original variant. Then with Omicron, trying to understand how much is this causing milder disease, and is that driven by something intrinsic to the virus, or is that just driven by having more people vaccinated, more people who have prior infection, more people with immunity.

So, I think that's one significant use of the data in an area where it's important to have person-level data. I think wastewater is another sort of exciting development, both for measuring overall levels of COVID, and also for detecting variants. But I think it's not a replacement for individual sequencing, because with individual sequencing you have person-level data of what variant did that person have, and were they hospitalized, did they die, 01:31:00those kinds of things.

Q: Yes. For your work, let's say like with, I don't know, like even like, with like the vaccines, or what you were doing as an EIS officer, all this work with sequencing and knowing about the different variants, I guess like when you're dealing with the Delta variant, since that's kind of where we're at in the timeline, how is all of these kind of advances in public health tech, advances in public health methods, I guess, is how is that really impacting like what you're working on, your day to day, or is it? Or is really not, like you're--it's a great advance for other parts, but not really affecting you personally kind of thing?

MILLER: That's a good question. I guess I should say that I've worked some with our molecular epi [epidemiology] team, but it's not my like, main work. This is 01:32:00really more--I think it affects their day to day more. But I think it affects the broader sort of day-to-day public health, just as we're trying to understand like, what's coming next. Where are you like, like when Omicron--I guess we're talking about Delta, but when Delta started, or what does that mean? That sort of takes us back to the summer, but I think at the time, there was this hope that vaccines would substantially control transmission, and maybe we wouldn't have any other, any more large surges, and then of course with the benefit of hindsight, like obviously Delta changed that completely. But at the time, I 01:33:00think we were trying to understand, based on the epi and sequencing data, how fast is Delta taking over? Also, what are the properties of that variant? Is it more contagious, how much more contagious?

Is it more severe, how much more severe? What does that mean for our next steps? That was, again like summer of 2021, it was kind of like oh, well maybe vaccinated people don't even need to test, vaccinated people don't need to wear masks. And so on, and like hopefully we're kind of coming out of the pandemic stage, I guess, that's a loaded term, but--and then the Delta variant really changed that. Looking back with hindsight, that seems very clear, but at the time, we were trying to sort that out in real-time. I think the same thing happened with Omicron. This was, I can't remember when exactly it was, I think 01:34:00it was like October or November, I guess, we started hearing the first reports coming out of South Africa, and initially some kind of limited data coming out of South Africa, and trying to understand what that was going to mean for us, and I don't know that we necessarily foresaw exactly what that would mean with the Omicron surge, but yes, I think that's sort of how it, I don't know if that exactly answers your question clearly, but yes, I think it's an understanding of what, how does this new variant change what's likely to happen in terms of cases or surges, and how does it change our response in public health?

Q: Do you see that, for I guess like the future, I mean do you see like there's a way to remedy this? I mean just like in your own personal opinion? It's taken such a big hit.

MILLER: Yes, that's a hard question to answer. I mean I think part of that is that I think for the public, especially before COVID, public health was often kind of invisible. For a few reasons, partly because like if you prevent something bad from happening, then that doesn't get noticed necessarily. Also it's just not part of people's day to day life, say the way that like clinical care is, part of people's day to day life, people don't necessarily interact directly with the health department very much. I think it's harder, maybe it's harder for people to have that, existing trust, or relationship, or whatever, 01:36:00with the health department.

I think public health in the U.S. has also been underfunded for a long time, and that probably partly relates to it being kind of out of sight, out of mind. But I think that's made the COVID response more challenging, then it sort of becomes a self-fulfilling prophecy, like if you don't have the resources in place, and the people are frustrated that there's not enough testing, and then they're unhappy with public health because of that, it's sort of a negative cycle of like well, if there were more resources in place to start with, and a stronger public health system, then we'd be better able to respond to crises. But in the absence of that, then it's like people have developed a negative opinion, because things don't go as well as they should have. But I don't know, I'm sure 01:37:00there are other people who can give a, have more experience with this, or could give you more comprehensive or eloquent analysis.

Q: Yes. Do you have any other reflections? Maybe about the EIS officer training or just the effects of COVID on everyday life? What's the future going to look like, I guess, in your mind? You've already really touched on a lot of great topics, I'm just trying to, you know--

MILLER: Yes.

Q: --broaden it just a little bit to other topics we've talked about.

MILLER: Sure. I mean I think there's been less impact on my own everyday life with COVID than for most people, for a whole range of reasons. I mean you know, my partner and I both have good, stable jobs, we don't have kids, and I think you know, having kids during COVID is, from the experiences of friends and colleagues, seems very stressful, we don't have kids right now. We have the, we 01:38:00have insurance, we have access to resources to keep ourselves safe, we've been able to work remotely, all of those things. Even from like a quality-of-life standpoint, most of our hobbies are sort of outdoor activities, and so that hasn't been as affected by COVID. So, I think from a personal level we feel like we're--in the grand scheme, we're very, very fortunate. I think thinking more broadly about the future, it's been hard to make predictions about COVID, and we were kind of touching on this, like every--when people were kind of saying oh maybe COVID's getting better, or it's going to be over, or whatever, and then that proves to not be true, and I think it's--so I hesitate to make too many--

Q: You jinx yourself kind of thing, yes, yes, so.

MILLER: I hesitate to make too many predictions, but I think-- yes, I think I just worry about this feeling of like, going back to the normal, or going back 01:39:00to 2019, when I wish the focus were more on like the, I'm trying to think how to express this. That there is no going back, like the world has changed, and we can't just go back, and we have to figure out what does a new normal look like together, and ideally a new normal where we're all trying to keep each other safe while we still go about our lives as much as we can. And so I wish there were more of a focus on like, what have we learned, and how can we construct a new normal together, and it feels like sometimes the mood is more just around like, let's go back to 2019.

Q: Is there anything else that we haven't covered that you want to share?

MILLER: I guess in terms of the, we touched on this a little bit, but I think in 01:40:00terms of the future of public health, I hope that these, on a more hopeful note, I hope that these collaborations and partnerships that have either developed or even strengthened because of COVID will continue to be a part of public health going forward. I think the collaboration with labor and industry, the collaboration with Department of Corrections, or you know, the collaboration with university partners, I think that's been a bright spot amidst all of the sadness and tragedy of COVID, and so I hope that those will continue to be a part of public health work going forward, and of how we sort of structure our public health systems going forward, and I hope that this will be a, I worry 01:41:00this won't be the case, but I hope that this will be also a reminder of the importance of public health, and of pandemic preparedness

This probably won't be the last thing pandemic of my career or my lifetime, and so I hope that there'll be more of a sense of like, building those partnerships and strengthening public health for the, both for COVID and also for the next pandemic.

Q: Yes, for sure. Well thank you, Dr. Miller. That concludes our recording, so I will stop recording right now.

[END OF INTERVIEW]