Melanie Firestone

Q: Today is Wednesday, March 16, 2022. This is Mary Hilpertshauser for the COVID Oral History and Memory Archive Project. I am in Atlanta, Georgia, and I will be talking to Dr. Melanie Firestone, who is in Minneapolis, Minnesota. We are recording through Zoom. Dr. Firestone, welcome to the project. Do I have your permission to interview you and record this session?

FIRESTONE: Yes.

Q: Dr. Melanie Firestone is a member of the 2020 class of CDC's [Centers for Disease Control and Prevention] Epidemic Intelligence Service. She received a BS [Bachelor of Science] in health and exercise science from Wake Forest University, and an MPH [Master of Public Health] in epidemiology from Columbia University. Dr. Firestone was a research scientist at the New York City Department of Health and Mental Hygiene. She was involved with numerous public health responses, including Ebola in 2014, and Legionnaire's disease in 2015. In 00:01:002020, she completed her doctoral degree in environmental health, focused on improving public health surveillance to drive declines in foodborne illness at the University of Minnesota. Currently, she is an EIS field officer assigned to the Minnesota Department of Health.

Welcome to the project. To start things off, can you tell me a little bit about your family background, and the community where you grew up?

FIRESTONE: Sure. I grew up in Charlotte, North Carolina, and I lived there up until my senior year of high school. Most of the time that I was growing up, my mom was actually a student and a teacher herself, so she went back to school when I was about seven years old and finished her bachelor's degree that she had 00:02:00never completed when she was in her twenties, originally, and then immediately went right into graduate school, and did a master's in education while working full-time. I grew up going to a lot of college and master's-level classes, which sort of was an inspiration to me, and helped me realize that I always wanted to do some sort of advanced degree. But at the time, I wasn't sure what that was going to look like.

Because she finished her master's degree, she started looking for new jobs, so I actually moved my senior year of high school, which is sort of most people's worst nightmare, but I was okay with this, because I had a lot of friends who were older than me, and a lot of them had graduated. We packed up, moved about an hour and fifteen minutes north of where we had been living in North Carolina 00:03:00to Wilkes County, North Carolina, which is the largest geographically in the state, but is a pretty small county population-wise. I started fresh my senior year of high school, making new friends, and really had to learn to become less shy, otherwise I would be eating lunch alone every day.

It ended up being a really positive experience, it was a huge transition time, because I'd grown up in a city, I had moved to a rural area, that same summer that we moved, my brother moved to Japan, and we knew that he was probably going to live there for a very long time, if not always, so before the start of my senior year, I not only moved, but also was no longer able to see my brother 00:04:00every day, which was quite a big change.

Q: After high school, you went to Wake Forest?

FIRESTONE: Yes, so Wake Forest is only about 45 minutes from where I ended up graduating from high school. It was pretty close, and my dad was still in Charlotte, so it was only about an hour and a half from him, as well.

Q: Oh, okay. Then what makes you go on to get an MPH in epidemiology, of all things?

FIRESTONE: While I was a student at Wake Forest, I started working with the football team, so we were a Division I school, and so our football team was pretty competitive, and I worked as a student athletic trainer during this time. I originally, I always knew I wanted to do something with people.

I originally thought maybe I'd become a dietician, or a physical therapist, or 00:05:00something along those lines, and in my first season of working with the football team, one of the full-time athletic trainers asked me to come and look at one of the defensive linemen's knees, because it was swollen, and he wanted to use it as a learning experience for me while I was considering becoming a physical therapist. He told me to touch this person's knee, I touched the knee, felt how swollen it was, walked out of the room, and fainted in the hallway.

I knew that that was not going to be the right fit for me. But fortunately, at that time, there was a professor who had started a minor program in health policy and management, and so I had, that same semester, I was taking a basic 00:06:00undergraduate-level epidemiology course. I realized that I'm not going to be able to help people at the individual level through some sort of medical career, so I just dove deep into learning about public health and realized that working at the population level was going to be a better fit for me.

Q: Wow. What made you go to Columbia [University]? That's a little bit further away.

FIRESTONE: Yeah! My family is actually originally from New York, so I have strong ties in New York, my dad is from the city, my mom is from Long Island, and my brother was born on Long Island. I'd always sort of had an interest in the city and being there. But while I was taking, or excuse me, while I was applying to master's programs, I took a history of health and medicine course, we were required to take a history course, and when I saw that there was one 00:07:00about health and medicine, I knew that that was something I really was interested in. There were a lot of common themes throughout that class, but one of them was how many infectious diseases were really discovered, or really became problems, in New York City first.

So, once I had that realization, I decided that that was going to be a really good fit for me to study public health at the place where a lot of things happened first, and where they had to deal with problems like hygiene and sanitation before much of the rest of the country had to.

Q: Well, it's a large population in one spot, yeah.

FIRESTONE: It is, it is!

Q: So, while you were doing that, were you involved with the Ebola outbreak? You must have been because that was sort of --yeah. Go ahead.

FIRESTONE: Sure. While I was a student at Columbia, I started working as a student intern in injury and violence, so that was within the environmental 00:08:00health group. After I finished my master's in public health, I started--

Q: What year was--

FIRESTONE: I'm sorry, go ahead.

Q: What year was the master's in public health?

FIRESTONE: 2013, so it would have been before then, yeah.

Q: All right.

FIRESTONE: After I finished the MPH, I started working in chronic disease prevention and tobacco control, and after a little bit of time, there was an opening back in the group where I had been an intern, back in environmental disease and injury prevention. I transferred back to that group after a little bit of time in chronic disease prevention and tobacco control, and while I was there, I was able to get involved with several emergency responses on the environmental health side. The first one was working with New York City's 00:09:00response to Ebola. This was in 2014, when there were a few cases of Ebola popping up in the U.S., primarily travel associated. In New York City, because there are so many airports and these airports have so many international flights, there was several aspects of the response. There was monitoring for people who were coming in, travelers coming in, making sure that we were giving them thermometers so that they could do some self-monitoring, and then there was also the response to a New York City doctor testing positive for Ebola, and ensuring that the healthcare systems were coordinated, and were able to respond as needed, had all the resources that they needed, and then also, managing the 00:10:00public response, and the risk communication to the public.

Q: You were a contact tracer, or helped people with contact tracing?

FIRESTONE: I was actually sort of helping with the logistics of actually running the response during this time, so I was responsible for helping ensure that we had all the information we needed for meetings, coordinating information from different resources, coordinating staffing to cover the different roles, and so I was participating in a lot of the meetings, but I had a pretty junior role at the time. But because I was watching all of what was happening around me, I realized that this was something that was really interesting to me, and something that I'd like to be able to have a bigger role in at some point.

Q: Was that your first look at CDC and how it worked?

FIRESTONE: Yeah, I would say this was probably my first time working interagency, so New York City and working with CDC partners.

Q: Did you continue on there? Because you also worked on-- responded to Legionnaire's disease a year later.

FIRESTONE: Yeah, so about a year later, there was another major response in New York City for an outbreak of Legionnaire's disease that was in the Bronx, and that the city was sort of coordinating the response for. Because I was in the environmental health group at this time, we had a pretty important role, because our inspectors were the ones that were going out, looking, responding to the 00:12:00cooling towers, trying to identify the source in collaboration with the epidemiologists. This experience, I was still in a fairly junior role, but I was able to see much more of the response itself, and I actually helped with integrating the CDC team with our New York City team, and sort of helped kind of serve as a liaison there.

That was when I really learned about the EIS program. Some of the people from the CDC team had been former EIS officers, and had gotten a lot of experience through that, and then they had a point of contact of the New York City EIS officer at the time, and so I got a better idea of both how we do these outbreak 00:13:00responses, how we coordinate across resources, and also really got to see firsthand the type of work that EIS officers get to be involved in. So shortly after this outbreak occurred is when I began applying to PhD programs so that I could hopefully become eligible, and hopefully get into the EIS program later on. This was in 2015, so I applied to PhD programs that year, and started in 2016.

Q: That PhD program though was in environmental health?

FIRESTONE: Yeah. Because I had this experience of working on the environmental health side of the Legionnaire's disease response, I really developed an interest in sort of the intersection of environmental health and infectious 00:14:00diseases. I knew that I wanted to study infectious diseases, but I wanted to have an environmental health focus, and so the University of Minnesota was actually the perfect program for me, because there was an infectious disease epidemiologist working in the environmental health division who's an expert in foodborne diseases. His past experience was working at a health department, working at the Minnesota Department of Health.

When I first met him and told him my interest in sort of this intersection of infectious diseases and environmental health, and that I was coming from a government background, we immediately were in agreement of the aspects of public health that we enjoyed working on, and it was a really good fit for a program for me.

Q: It sounds like it, yeah. Can you explain exactly what is environmental health?

FIRESTONE: Sure!

Q: Talk about it, no one explains it.

FIRESTONE: Yeah. A lot of times when we talk about environmental health, we're thinking a lot about the traditional environmental health of there might be an environmental toxin that might be making people sick, or a chemical that might be making people sick, so there's a need to go out and do a risk assessment and understand sort of the risk of this environmental condition, and how that might be impacting health. The PhD program that I was a part of looks at environmental health in a lot of different aspects, so that would include occupational health, so worker safety and that kind of thing. Then also, this intersection of infectious disease and the environment.

Most of my doctoral work focused on restaurants and food safety in restaurants, so ensuring that, or finding ways to improve the restaurant setting--I'm sorry, I'm saying that not well. Let me pause for one second, if that's okay. I've said this like a million times in my life, and now, I'm suddenly forgetting how to speak.

Most of my doctoral work looked at restaurants as a setting for foodborne diseases. A lot of environmental health work involves sort of doing the regulatory side of restaurants and that kind of thing. But my doctoral work focused on using information from sort of the regulatory side of environmental 00:17:00health, restaurant inspections, that kind of thing, and seeing if there's information that we can learn to then apply it to outbreak response, and our understanding of how foodborne diseases are transmitted, and to identify ways that we can prevent transmission in the restaurant setting.

That was sort of a mouthful, sorry.

Q: Well no, that makes sense. I mean I understand the environmental health part, it's the foodborne illness and the infectious diseases is a new one for me. Interesting, very interesting. Okay, so--

FIRESTONE: Then I guess another aspect of it too--I'm sorry, I just dropped my pen, let me pause for one second.

Q: Go ahead.

FIRESTONE: Another aspect of it as well is environmental health, or of environmental health with infectious diseases, is the component of vector-borne 00:18:00diseases. Mosquitos can transmit many diseases and are a huge problem for much of the world. So infectious diseases with an environmental health lens can include things like vector-borne diseases and looking at the environment and the conditions that lead to mosquito population growth, and then how that impacts human health.

Q: Oh yeah, that would, yeah, that would be a malaria-type thing, or also--

FIRESTONE: Dengue, and--

Q: West Nile.

FIRESTONE: --West Nile, yup, Zika.

Q: Oh yeah, Zika. That is a lot more than I thought it was. Okay! Now you're sort of, got your toes dipped into the EIS field, how did you finally decide to commit, or how did they finally recruit you?

FIRESTONE: As I was nearing the end of my time in the doctoral program, I began 00:19:00looking at the timeline for EIS, because I knew it was something that I had always been interested in, and so I actually applied to the EIS program in the spring of 2019, and I found out in August of 2019 that I was accepted for an interview, which was in September, and then a month later in October of 2019 is when I found out that I was accepted into the program. I knew that it was something I really wanted, but it's such a competitive program that I was really hoping that I would get in, but there's so many incredible, and talented, and accomplished people applying, so I was sort of nervous about the timeline, because it is a long timeline for the application process.

But fortunately, the timing worked out really well, so I accepted in October of 2019, and recruitment wasn't until May of 2020, and as a doctoral-level scientist, we have to defend our dissertation by the end of March of the year that we start EIS. I quickly became busy trying to finish my doctoral work, and then with that long period of time between accepting and recruitment for specific positions, I began sort of finishing all of my work, then with the backdrop of the pandemic starting to emerge.

Q: Right. Did you have an interview in person with someone from the EIS program? How does that happen? You apply, they accept you, you get a letter, do you get 00:21:00an email?

FIRESTONE: Yeah, so when you get an interview, you have to--or prior to COVID, you would fly down to Atlanta, interview for a day, it's a full-day interview, there's multiple components of the interview, and then you fly home, and then you wait about a month to find out if you're accepted or not. We were interviewed in-person, the classes since then have been virtual interviews, because of the pandemic. We interviewed in-person, went through sort of the normal process for EIS acceptance, and then by the time, before we were actually supposed to start, we--everything had changed.

Q: Sure, so your program starts in, I believe it's July, the month of July is 00:22:00when you start training.

FIRESTONE: Right.

Q: That was not in-person, or was that virtual?

FIRESTONE: That was a hybrid, so that was virtual, our training, but we, typically what happens is the field officers, or the NACHOS, the non-Atlanta-based [Center Headquarter] officers who are at headquarters positions, we all fly down and typically would stay at a hotel, and then we'd all do the class, summer course in person together. But for our class, because it was prior to vaccinations being available, there was a large surge going on, we flew down to Atlanta, and stayed in apartment rentals for three weeks, and did virtual courses from the apartment. And--

Q: Those apartments are across from the main campus, right?

FIRESTONE: Yup, and I think it's Emory Point.

Q: Yup, that's right. Yeah.

FIRESTONE: Yeah, so part of the reason we need to come down in person is because there's certain things that can't be done virtually, such as getting our computers, getting our badges, we have to get fingerprinted, we have to do medical clearance, that kind of thing. No matter what, there was a need for us to be there, so we ended up staying for a lot longer, because at the time that we had scheduled this, it wasn't clear if we would be able to be in-person yet or not.

Q: During that time, did you meet anybody else in your class? Were you able to get out of your apartment, or were you quarantined into these apartments?

FIRESTONE: Fortunately, we were able to have small get togethers as a class. It was a little nerve wracking at times, because we all really were excited to meet each other, and to get to know each other, but we didn't want to have these large gatherings, because there was a surge happening in cases at that time. We 00:24:00were able to get together in small groups with masks, and generally six feet apart, and still get to know each other. Because all of the field officers were staying at the same location, we would sort of run into each other anyway, and so we were able to kind of get together just by the nature of physically being in the same place.

So that was a really great opportunity for us to kind of lay the foundation, even though we didn't all get to meet each other, a lot of us were able to meet each other and get to know each other and start beginning to make friendships and find ways to continue communicating once we're back in our specific sites.

Q: Yes, because EIS kind of depends on knowing who everybody else is in your class, so you can use them as reference points around your work.

You don't know it, you can ask somebody else that perhaps knows it better than you. Now at this point in time, are you guys matched, or not matched to a program?

FIRESTONE: By the time we're at summer course, we are matched to a program, we go through that in May, and typically that's done in-person also, but because this was during the peak period where everything was shut down, we did a virtual recruitment, and then met in-person at summer course in July. So, everyone, for the most part, had moved if they needed to and were coming from their specific site, or if they were Atlanta-based, they'd already moved to Atlanta.

Q: Okay. Did you have many, I mean how does the matching process work? Let's try that one. I think it's kind of a magical thing.

FIRESTONE: The matching process, typically it is at the EIS conference, the new 00:26:00class that's coming in will have the opportunity to meet people from all the different positions, there will be tables where the supervisors will be available to talk to officers who are interested, and then you have a day of interviews, and then you put in your rankings, and then you find out, I guess about three to seven days later, it kind of depends on the year. So, for our class, we were the first class to go through this sort of virtual environment. People didn't quite have Zoom fatigue yet, but people were sort of figuring out how to go about the recruitment process. A lot of sites offered like, coffee 00:27:00hours, come have coffee on your own, at your own home, and talk to us about our specific site, and the work that we're doing.

For our class, it was actually a very long time period, I think it was three weeks that we did this, which was quite a long time. Typically, it's only about three or four days at conference, so we were spending a lot of time talking to people, a lot of time on Zoom, and it was, we started to get a little bit of Zoom fatigue, I'd say. It's hard to get to know people sometimes through Zoom, and there's a lot of informal chats that weren't able to happen as a result of this. But that being said, because there was a little more flexibility in the 00:28:00timing, people could sort of spend how much time they needed, they could really explore some of the positions a little bit more than they might have been able to otherwise, in a shorter time period.

Then the interviews themselves went on for several days as well, instead of just being one day of interview, just to accommodate people's schedules, and also because of the time zone differences, because not everyone was in Atlanta, and to sort of adjust that way. It's a very nerve wracking process in a lot of ways, because you are trying to figure out where you might be for the next two years, both physically, and what the type of work that you're going to be doing is, and what that's going to look like. That was sort of a huge relief to be able to go through that process, put in your rankings, and then find out where you're going.

We actually got our results the day before my birthday, and so I was already 00:29:00physically located in Minnesota, because I had done my PhD here, and so I found out the day before my birthday that I matched to Minnesota, which I was very excited about, but then I also realized that I wasn't going to be spending my birthday trying to figure out where to get a new apartment and whatnot, so that was sort of an interesting experience, because I had been waiting up to that time thinking oh, I'm probably going to have to move, and I'll probably be spending my birthday trying to figure out apartments and how to move to whatever city I end up in. That was sort of an interesting experience too, so I ended up getting to just enjoy my birthday a little differently that year.

Q: Yeah. The EIS conference is usually held in April, so that all happened in April?

FIRESTONE: EIS conference is usually the last week of April, or first week of 00:30:00May. This actually started right at the end of March, so it might have even been longer than three weeks for the whole process. Because I think there was several days of interviews too, so it was about a month-long process, at least, when it's typically a weeklong process.

Q: So, you matched with Minnesota to become a field officer. What does that entail?

FIRESTONE: Yeah, so field officers typically, we're a little bit different than people who are placed, our work is a little bit different than people that are placed at headquarters positions, because a lot of our work can vary significantly day to day. So, while a person in a headquarters position might be placed in a specific branch, working on a specific topic, we sometimes don't know what our day to day is going to look like, because an issue might arise in 00:31:00one part of the state that we might end up responding to.

I was very interested in being in Minnesota, because we have a great team of epidemiologists, and we also have a really great public health lab, and we are physically located next to our lab. They're separate buildings that are next to each other, but they're connected by a skyway that you don't have to go outside to go between the buildings. I knew Minnesota had a rich history of having a strong partnership between the epi [epidemiology] and lab [laboratory] teams, and that was a big part of my interest in being here. They also have a really good foodborne disease team, which is what I had focused on for my dissertation, so I was really interested in gaining outbreak experience with foodborne diseases, zoonotic diseases, waterborne diseases, because they had such a great reputation for that type of work.

Q: You're so close to the lab, you could be part of that.

FIRESTONE: Exactly.

Q: So, lab and epi typically are never together in the same buildings, because of their different tasks, but being that close it's much easier to get your collaboration going?

FIRESTONE: Yeah, it really depends. Some states have their public health laboratory pretty close to where their epidemiologists are seated. But Minnesota actually designed their new public health building very strategically, so it's the Department of Agriculture, the Department of Health, and the Public Health Laboratory, all connected. So, the Department of Agriculture and the Department of Health are in the same building, and then they're connected to the laboratory via the skyway. That was an intentional design, so that they could be better suited to respond to outbreaks, because there are certain foodborne outbreaks 00:33:00and zoonotic outbreaks that involve both the Department of Agriculture and the Department of Health. Then of course, we get the information that an outbreak is occurring, either through complaint-based systems, so people calling and reporting it, or through identification from our laboratory partners. That was a very intentional decision to have all three physically located together, to be able to respond better to outbreaks and public health emergencies.

Q: Because they're all interrelated. What was the first thing that you started to work on when you were at the Department of Health? If we're looking at, okay, so you started in July/August, August of 2020.

FIRESTONE: Yeah, so there were two things that I started on right away, as EIS officers, one of the first things we work on is our surveillance evaluation. In 00:34:00Minnesota, there was a lot of interest in understanding nosocomial [healthcare-acquired] transmission of COVID-19, and also looking at outbreaks of COVID-19 in hospital settings. But there wasn't a system, a surveillance system, to be able to identify these cases, or these outbreaks. One of the first things I worked on was trying to see what we could do to create a system to track nosocomial transmission, and healthcare clusters of COVID-19. At the time, there had been a lot of investigation into specific settings for COVID-19 transmission, so we were monitoring restaurants as an outbreak setting for transmission of COVID-19, special events and transmission of COVID-19, and that 00:35:00kind of thing.

But there really wasn't much in terms of hospital settings, and what we were able to do. Immediately I began working on trying to create a surveillance system, and responding to outbreaks at hospital settings, providing information about testing, how to respond to the outbreak, how to control the outbreak, and that kind of thing. That's something that I continued for most of my time in EIS, and have, sort of still have my foot in a little bit, but now there's a team that's responding to that more so.

Then at the same time, there had become a lot of interest in this large event that was happening right when I started, and how that might impact healthcare settings. In Minnesota, we're physically located next to South Dakota, and there 00:36:00was the Sturgis Motorcycle Rally that was happening the first couple weeks of August, right after I started. So, we had been hearing from healthcare facilities that there was concern about what to do if their staff were going to this event, because there were over 400,000 people, it was the first real major event that was occurring after most of the country had been shut down earlier in the year.

While I was working on sort of these, developing a surveillance system for healthcare-acquired COVID-19 and monitoring healthcare outbreaks, I also began looking into monitoring the number of cases that we identified in Minnesota among people who had gone to the Sturgis Motorcycle Rally [August 2020]. After 00:37:00initially finding several cases, there was interest in seeing how much spread might be related to people who had gone to this event and maybe caused by people who had gone to this event. I started looking at secondary transmission, and tertiary transmission, so COVID-19 cases among people who had not gone to Sturgis, but who had contact with someone who had gone to Sturgis, and then tested positive for COVID-19.

That was really the first big project that I did, and that was a really great opportunity to partner with our incredible public health laboratory, because I would review the epi data from case interviews, identify that there had been close contacts, and then we would look to see if we could obtain the specimens from both the people who had gone to Sturgis, and then their close contacts. By 00:38:00specimens, what I mean is their positive COVID-19 tests, so the sample that they had collected to see if they had COVID-19 or not.

We were able to get several of those samples from our partner laboratories, or ones that had been tested at our public health laboratory, and then our lab was able to do whole genome sequencing to look at the relatedness of the samples. Whole genome sequencing is a tool that we can use to essentially look at the genetic material of the virus and see how similar or different it is to other samples of the virus. It basically shows us the DNA fingerprint of the virus, and what we were able to see was that the introduction of COVID from Sturgis 00:39:00came through multiple channels. There were a couple clear clusters of people that did or didn't know each other, but had similar closely related viral sequences, and then there were others that had very different viral sequences.

What we were able to see is that some of the people who had close contact, and then tested positive, we were actually able to show that it was a related sequence and was likely from a person who had actually gone to the event.

Q: Is that one of the first large, or one of the largest clusters of where people were identified, like a whole bunch of people going to one event, and then from that one event, it had a lot more spread just because of that one event? That was one of the first ones, that was August and September, and that's 00:40:00even before we had a vaccine, vaccine comes around in December, but that's only for nurses and people working in the healthcare setting.

These people were congregating without any protection, or were they wearing, do you think they were wearing masks?

FIRESTONE: Yeah, so we don't know if people were wearing masks, but based on pictures from the event, almost no one was wearing masks in any of the pictures, so we don't believe that mask use was high at the event. But yeah, it was before protection from vaccines, and it was one of the first major events. So that was part of why there was a lot of interest in how this was going to impact communities, of people going to this event and then coming back. This was one of the first papers that really showed secondary transmission, tertiary 00:41:00transmission, from a large event of this type. There were a few others that came out around the same time, and we only looked at the impact in Minnesota, because as a field officer, most of my work is based in Minnesota, and looking at populations here. We only looked at Minnesota residents who had gone to the event and come back, and then looked at how it spread to other Minnesota residents once they were back.

Q: Fascinating. Then you had a variant surveillance project that you were working on too, which is interesting, because the more the virus mutates into people, the more variants you're going to get. This is like the next step to epi here. Tell me about the variant surveillance, and why you started doing that in January.

FIRESTONE: So, because I had this experience of working with our public health laboratory to do sequencing for this large event. Because I had been working with them to do sequencing for hospital outbreaks as well, when our public health laboratory first identified cases of the B.1.1.7 variant, the Alpha variant, I was one of the first people that they called, and so part of the reason for that is because there was interest in we knew we had found this variant, and then they wanted to see what information we had from case interviews, such as did the people travel, had they been in a country that we knew transmission of the Alpha variant was occurring.

When I got this call from a person at the public health laboratory, I 00:43:00immediately began looking at the epidemiology data that we had and seeing what I can learn about it so that we could get a better understanding of how this variant was emerging in Minnesota. This was in early January that we first identified cases, and it was several cases at once, I believe it was five, so it wasn't just one right away, of the Alpha variant. We, in December of 2020, realizing that there were all of these, it was likely that variants were going to emerge because of the nature of how viruses mutate, and how much rapid spread had been occurring, our public health laboratory began doing routine surveillance for variants.

Instead of focusing on just sequencing for special investigations, such as looking at Sturgis, and looking at the relatedness of sequences of people who 00:44:00had gone to the event, they began doing more routine testing, so they began receiving specimens from partner laboratories on a weekly basis that they would then sequence to use that to monitor for the emergence of variants. The first cases of the Alpha variant that we identified in Minnesota were identified through that mechanism. That again was in early January [2021].

Fast forward about two weeks to the next cycle of sequencing, and they had been sequencing roughly every few, I think it was about once a week, or once every other week. So two weeks later, they had gone through the sequencing again, and there was a CDC fellow working in the public health laboratory, and she 00:45:00contacted her supervisor and said, I think I found the Gamma variant, so the one that first was identified in Brazil. At the time, there had been no other cases identified of this variant in the U.S. Immediately, he began looking at this, our laboratory partner began looking at this with his team and the person who identified it, and then they were all in agreement that this looked like the Gamma variant and matched the sequences that were in the publicly available data system.

Then again, they called me to see what information we had on the epi side for this. The first thing I saw was that the variant was identified in a person who 00:46:00had recently traveled to Brazil, and so that was sort of this aha moment for us of the lab feels confident about what they're seeing, and then the epidemiology made sense with what they were seeing at the time. That was a really fascinating experience, and then I ended up leading the investigation to try and get more information about where the person had traveled, if there were any other close contacts, that kind of thing, if they had tested positive. Then this led us to publishing an MMWR [Morbidity and Mortality Weekly Report] that was about the identification of the first Gamma variant, P.1, in the U.S. [March 12, 2021]

Q: Wow. Did you have to handle any kind of like, press or media during this period of time? What was that like?

FIRESTONE: Yeah. There was a lot of attention after publishing the MMWR about 00:47:00Sturgis [November 27, 2020], and I did several media interviews related to that, primarily responding to written questions and that kind of thing. So, there were certainly a few articles that came out after that, there was also some interest after the Alpha and variant publications. That, those were published in a very short period of time, they were Notes from the Field, MMWR articles, so they're shorter articles, but I published both within about a month, I believe. That was an incredibly busy time, because I was doing the [case] interviews, and writing a paper, and working on the review for, during the second paper I was working on the review for the first paper, as I went through all of that.

There was some interest in, especially the Gamma variant, because we were the 00:48:00first in the U.S. Not only were there some opportunities to speak to the media about our story, but there were also a lot of opportunities to talk to other states. They were really interested in learning what we had done to be able to identify this, and how we worked so quickly to be able to do this. So that was a really fun experience too because we got to tell our story, and at the time, the sequencing director, at the time that we identified the Gamma variant, the director of sequencing at our public health laboratory was on his way to get his COVID vaccine.

Q: Oh yeah. That's March?

FIRESTONE: No, this was in January. He was a prioritized group, because he was working physically with the virus.

Q: Oh yeah.

FIRESTONE: He--I'm sorry, I'm sort of jumping around a little bit.

Q: That's all right!

FIRESTONE: I hope that's okay.

Q: No, we're still in the same period, we're January to March, 2021.

FIRESTONE: Yup. He called me, or he messaged me actually, I should say. For that one he didn't call me, but he sent me a message on Teams as he was on the train going to get his vaccination, to look into this. That was sort of fascinating. We did talk to the local, our local newspaper here about that experience of him being on the train, verifying with his team what was seen while on the train, and then contacting me on the train, and then immediately reporting it to all of the leadership team, too.

Q: I'm going to ask you a couple of questions to follow up here. Do all public health labs have sequencing labs?

FIRESTONE: Not all of them do. There are certain laboratories that are just 00:50:00smaller and don't have quite the capacity, we're really lucky in Minnesota that we have the capacity here, and such a great team working on it. Occasionally we do help out other states with sequencing, and that was happening sort of early on especially as places were ramping up their sequencing efforts. Our public health laboratory can do sequencing, and then we have a couple of partner laboratories in Minnesota that also assist with sequencing. So, we have a certain amount that we can do each week, and as the variant surveillance was increasing, as variants began emerging, our partner laboratories began doing more sequencing as well, so that we could increase the number of samples that we were sequencing each week, so that we could better identify these variants as they emerged.

That was sort of occurring in the backdrop of us identifying these was ramping 00:51:00up sequencing both in-house and through our partner laboratories. Then, beyond that too, we occasionally do provide sequencing for other states as needed. States are set up differently too, some, most of their sequencing might be done through a university, or a local medical facility, rather than through the public health laboratory.

Q: Yeah, each state has different setups, which is sometimes hindering to a large system like this. My next question was about EIS. Did EIS, in your two-week training, give you media training, how to respond to the media? Okay.

FIRESTONE: Yeah, so they did give us media training -- Sorry, I have to cough. As a part of our summer course, we did do a media training, and we were given 00:52:00the contact information for the people that we would need to contact if we were, if a reporter reached out to us to do some sort of media response. At the time, that we published the Sturgis article, I ended up doing a little more media training, because we anticipated that there was going to be a media response. I was fortunate to get sort of this extra on the job training, on the spot training, as I was going through it. That was really nice.

We have a really great team in CSELS [Center for Surveillance, Epidemiology, and Laboratory Services] and then they also partnered with the EOC [Emergency Operations Center] media team, so I was fortunate, because I got to work with 00:53:00the CSELS person, and the EOC person, sort of just to see how the interview might go, and get a better understanding of sort of how to frame my responses, just to help tell a more cohesive story.

Q: Okay. Did you ever feel that you were free to speak on whatever you needed to speak on, so that the science could come out?

FIRESTONE: Yeah, I think the biggest challenge, rather than not being able to say things freely, the bigger challenge for me was really how to explain a complex thing in an understandable way without diluting the science. I think that that was something I definitely learned to do better, which is a great experience. But there was never a time that I felt like there was something I wanted to say and couldn't say. Which is important.

Q: During this period of time, were you, I mean it's early January through 00:54:00March, people were starting to get their vaccines, did you get your vaccine about this time, or was it later?

FIRESTONE: I did, I was really fortunate, I got vaccinated the week that we identified the first Alpha variant cases in Minnesota. In the backdrop of working on doing these investigations, conducting more interviews, trying to find more information, so that we could understand risk and help tell people how to better protect themselves as they needed to, I was feeling the side effects of the first dose, and was, had a headache for about four days during that time. Then I actually, unrelated, I had sort of a medical emergency separately during 00:55:00that same period in January, when I was going through all of this.

That was a really interesting time, because I was physically not feeling well while I was working actively to try to find ways to inform others of how to better protect themselves.

Q: Did you have to go to a healthcare setting yourself, for your own care?

FIRESTONE: I was actually in a healthcare setting when it happened. I received allergy shots, and occasionally when you're receiving allergy shots, it's possible to have a systemic response, so I actually went into anaphylactic shock in the doctor's office after receiving allergy shots.

Q: Okay. So, you still had to go into the doctor's to get those shots, and that must have been sort of a different way you had to do it for this period of time, because we're in a pandemic, a lot of people weren't actually going to their doctors, but you were doing that. Was that, did they have different protocols in 00:56:00place at that time, what did it look like?

FIRESTONE: They did, they had masking in place--

Q: For future record, because people don't understand what we went through.

FIRESTONE: Oh sorry, can you say that again? It cut out for a second.

Q: This is just for future reference, because a lot of people will not understand what we were going through, like if you just had to go to a doctors, it was not the normal, it was like this, what you're about to explain. I'll shut up.

FIRESTONE: Oh, got it. Okay. I was still going to the allergist to receive allergy shots during this time, and that was especially important, because one of my big allergies is dust, and indoor allergies, and so I was spending more time indoors than I might have otherwise. This was really the only doctor that I was still regularly seeing during that time, because a lot had switched to telehealth, and that kind of thing. I go in about once a month for shots, and prior to this, there were no appointments, there were just drop-in 00:57:00hours of when you can go and get your shots. The biggest adjustment was that I had gone from just going whenever it was convenient for me to get shots, to actually having to make an appointment so that they could control how many people were in the office, and make sure that there wasn't a lot of people in close contact waiting for their shots.

They also had implemented masking, and extra cleaning protocols during this time. It's pretty hard to give somebody a shot without being in close proximity to them, so the nurses were all wearing N95s, eye protection, and fortunately, were some of the first to be able to get vaccinated. I was fortunate that I got vaccinated very early as well and was able to feel more comfortable going into healthcare settings as needed during that time.

It was really interesting to have this experience of going into anaphylactic shock during the pandemic though, because when you're wearing a mask and then suddenly physically can't breathe, the first thing that is natural to do is to rip the mask off to try to breathe. I had been trying to still keep a mask on, but I couldn't breathe, because my throat was closing up. I remember walking from one side of the waiting room, where I was waiting after my shots, to the other side, and trying to keep my mask on, because there were other people nearby, and I didn't want to be the person not wearing a mask when everyone else was wearing a mask, I didn't want to risk potentially infecting somebody if I had COVID and didn't know it. But I had to physically walk across the room while 00:59:00I couldn't breathe to be able to get medical care across the room.

As I'm walking across this room, a nurse is holding my arm, I'm coughing, I can't breathe, trying to keep my mask on, starting to get really sweaty and hot, and the doctor comes by, takes one look at me, looks at the other nurse that's behind her, and says, "Epi pen, now." So, I get into the room that they are providing treatment, my mask is off at this point, because I'm coughing, trying to breathe, they help me take off my sweater, because it's January in Minnesota, it was very cold, so that they can--and they get the epi pen in my arm before I'm even laying down. It was an incredible response. The whole time I'm feeling awful that I don't have my mask on in this healthcare setting, but I'm also actively trying to be able to breathe again.

Q: Wow.

FIRESTONE: It was pretty incredible.

Just the response from the nurses and the doctor was just, I still can't believe 01:00:00how fast they had that epi pen in my arm. This is their job, they're used to it, but still it was just an incredible care team. I was really lucky.

Q: Wow, that's an incredible story. When you did get your shot, what was the feeling you had when--not like because you had a headache for four days, but what was the feeling you had after you had the shot, you got the band-aid, and you're walking away, what is that feeling?

FIRESTONE: My COVID vaccination?

Q: Yes, the first one.

FIRESTONE: The first one, yeah. I was very, very excited to get my first dose of the vaccine. I remember just being in line, waiting for it, and thinking I'm so close, I'm so close to being able to have this extra level of protection here, and I'm so lucky to be able to get this so early. I just kept thinking like, I 01:01:00want to shout from the rooftop how happy I am to be able to get this. But I was also nervous that, I don't know, I didn't want to count my chickens before they were hatched, even though I was in line.

While I was waiting, because you have to wait for a little while after to make sure that you have no side effects, it's the same for allergy shots, too. But I just remember sitting there like, I got this, like this is progress, this is incredible, we got this vaccine created in an incredible amount of time, and just thinking how amazing science is, really, and that we were able to do this. I actually wore a shirt that said, "Science is like magic, but real," when I was there.

Q: That's wonderful, yeah. Wow. That's a great time, January through March.

FIRESTONE: Yeah. It was busy, it was probably the busiest time of my life.

Q: It was very busy! Yeah. Wow, did you ever slow down? Let's take you to your first deployment, which I think is the household transmission.

FIRESTONE: Yup.

Q: You were deployed to?

FIRESTONE: I was deployed to San Diego, California, and I was working as a part of the epi task force for the COVID-19 response to do a household transmission study of COVID-19. We were interested in looking at how COVID was spread within households, and if it varied by whether or not the index case had a variant case 01:03:00of COVID-19. At this time, it was again, the Alpha variant primarily that was being spread. We were looking to see if there were other variants as well, because Gamma had emerged in the U.S. at this time as well, but it was largely the Alpha variant. As a part of this, we were going into people's homes, doing COVID testing, doing blood samples for antibodies, and then also doing environmental sampling to see if we were identifying COVID on surfaces, or SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] I should say, on surfaces.

Q: Okay. Were you, when you say you're taking samples, are you actually physically taking the samples, or was there somebody else who was doing that?

FIRESTONE: I did some of the environmental sampling, and then I also assisted the public health nurse with the biological sample collecting, or collection. 01:04:00She would do the blood draws, and the nasal swabbing, and administer the--we did a saliva test as well during that time. Then I would be the one right there documenting everything, sealing everything, and putting it in the respective storage containers that we had.

Q: That was your first actual in the field deployment, how did that feel, did you, were you prepared, or was it something new, or?

FIRESTONE: Yeah, it was really interesting to get out in the field for the first time, because when I first started EIS, I was going into the office quite a bit, but as the first, as the fall wave kind of came through, more people were staying at home, so I started staying at home more as well. This was sort of right at the end of that time period where people were really primarily at home, and really not going to the office very much.

So, it was fascinating to be out in the field and going into people's homes, because not only had I not really been around colleagues much for the last couple months, but then we were actually going into the homes of people who were potentially actively infectious.

Q: Yeah. Did you have PPE [personal protective equipment] that you were wearing? Did you, were you around --

FIRESTONE: We did. We tried whenever possible to do the collection outside, but either way, whether we were indoors or outdoors, we were in full PPE, and so I had been coming from Minnesota, which is very cold in March still, and then we were in San Diego, which is much warmer in March, and so there were some days that it was very warm wearing full PPE. But-- so that was sort of an adjustment too. Sometimes, wearing full PPE isn't as bad when it's very cold out. But yeah, 01:06:00it was really great to see, and that was one of the first times I had been able to get together with other EIS officers as well, because there were several other officers that were part of this response. It was a huge team working on this study, so it was really a nice opportunity to meet people from other parts of CDC, see some EIS officers that I hadn't gotten to see in a while, and then really work on trying to increase our knowledge of variant transmission in the U.S. It was really great to be a part of.

Q: Where were the samples sent? What lab got them?

FIRESTONE: We partnered with the health department in San Diego County, so they did some of the testing, and then some were sent back to CDC.

Q: Okay. How many samples do you think there were that you guys all did?

FIRESTONE: Ooh, that's a good question.

Q: Hundreds, thousands?

FIRESTONE: I don't, I guess I'm not sure. I think there were maybe like sixty households, around sixty households, for this particular part of the study, and then it could vary between like, three or four samples per household up to more than ten, depending on the size of the household, and how many people were participating. At this time too, they also had a similar study going on in Colorado, so there would have been samples from that as well.

Q: Okay. Great. Then once you got back to Minnesota, put your coat back on, what happened, what was your next assignment?

FIRESTONE: When I came back, I had sort of been continuing all of the hospital outbreak work, and nosocomial transmission work during all of this, aside from when I was deployed. So, I went back to some of that work, and then I began also 01:08:00working on a vaccine effectiveness study, and so that was focused on the correction setting, there were several prisons in Minnesota that had experienced outbreaks, and some were as vaccines were being rolled out, and some occurred after a large vaccine administration had already occurred. I began working on designing a vaccine effectiveness study with Minnesota partners, and CDC partners to try to see what we could learn about vaccine effectiveness in the corrections setting. Unfortunately, we were not able to get much information from these studies, and there are a couple of reasons for that.

One is that they were relatively small sample sizes, because it was a limited 01:09:00population, it wasn't the total U.S. population or the total Minnesota population, we didn't really have enough power to be able to make comparisons between vaccinated groups and unvaccinated groups to really understand vaccine effectiveness. But then also, this was a really good example of sometimes it's hard when you don't know what you don't know. We were, there was a lot of information that we knew that might potentially impact the results that we were seeing, and so when you have an idea of some of these things that might be impacting the results, you want to take that into consideration to make sure that the results that you're seeing logically make sense and are meaningful.

But in the corrections setting, there was just a lot that we didn't know about these potential confounding factors, so we didn't know, for example, if people who lived near each other were more likely to be vaccinated than people who didn't live near each other. Because we didn't have a lot of information on some of the movements within the facilities, we really didn't have a good way to assess risk during these outbreaks, and so we weren't sure if people who were getting COVID, if it was related to whether or not they had the vaccine, or if it was related more to their risk within the facility, and that kind of thing.

Q: Because there's a lot of people packed in a facility, and it's hard to figure that out, yeah.

FIRESTONE: Right, exactly. That was something that I worked on once I returned, and then I also, during that time, deployed to Portland, Maine, for a response 01:11:00to a tuberculosis outbreak.

Q: Unrelated to COVID? So, you're still doing--

FIRESTONE: Unrelated to COVID.

Q: So finally, you're doing something that's not COVID-related.

FIRESTONE: Exactly! Not COVID-related, but still within the backdrop of COVID. Again, we're still wearing proper PPE, there's still all sorts of COVID precautions in place while we're doing tuberculosis and STD [sexually transmitted diseases] testing in homeless shelters across Maine.

Q: Interesting. I mean how did that work? The people are in shelters, did they stay in shelters, or were they free to go elsewhere during the day, and they returned to the shelter? How did that work? How do you track down people and tell them results?

FIRESTONE: Yeah, so each of the shelters had different sort of protocols for whether or not people were around during the day or not. Some shelters, people 01:12:00had more permanent rooms in these shelters, and were able to stay during the day, and others, people would go out during the day, and then just come back at night when the facility reopened for the day. As a part of this, we worked closely with the public health nurses, and the shelters themselves, to be able to give people their results after the fact. Some people, we had a general idea of where they'd be, and we also asked where people typically spend most of their time, so that the public health nurses and the shelter staff could find them to be able to give them their results.

Q: But were they interested in the results, or was this just something that, another thing they had to do, and they really weren't interested if they had TB 01:13:00[tuberculosis] or not, or they were?

FIRESTONE: Yeah! We had a pretty good response, people were pretty interested in what we were doing, and they would tell their friends that we were doing this, and so we'd get other people through word of mouth that way. I think people were typically interested in their tuberculosis results, because they knew that there had been an outbreak over the past couple years, that was sort of a slow-moving outbreak over time. But there were other people that were more interested in STD results, as well, so while our primary goal was to look at, and to identify potentially missed tuberculosis cases, or people with latent TB, we offered STD testing as well, and so some people were really more interested in the results of that.

Q: If they tested positive for either the STDs or the TB, did you offer 01:14:00treatment, or was their treatment through the public health departments that they could go to?

FIRESTONE: Yup. For people who tested positive for tuberculosis, and latent TB, they would receive care through the health department, and Maine would provide care, free of charge, because care can be very costly, and if they catch it when it's in the latent phase, it's much less costly for, to provide care. They were incentivized to provide this care, because they could prevent further spread, and then also it would reduce healthcare costs later down the line. For STDs, they would refer them to a clinic, and they could get care through either public health clinics, or other local clinics.

Q: Was there any COVID testing tucked into this?

FIRESTONE: There was not COVID testing tucked into this, and part of the reason for that, I believe, was just limited resources and time spent, we didn't want to make it too challenging for people to actually get testing, we really wanted them to be able to come, do this quickly, and kind of move on. But there was also a lot of other resources to provide COVID testing for this community, so the focus was really on increasing tuberculosis testing, which had been harder to get at this time.

Q: How long were you there doing that?

FIRESTONE: I was there for three weeks.

Q: All right, so then back to Minnesota to do what?

FIRESTONE: Back to Minnesota to continue the vaccine effectiveness study.

Q: Oh, I've got to ask you something.

FIRESTONE: Yes.

Q: You must explain what is nosocomial.

FIRESTONE: Oh, nosocomial means healthcare acquired.

Q: Okay, great. All right, so what about this unexplained death surveillance that you talked about earlier?

FIRESTONE: Yeah! In Minnesota, we have a surveillance system called the Unexplained Death Surveillance System. We call it UNEX for short. This is a pretty unique surveillance system. There had been some funding in the '90s to create systems like this, but once the funding was cut, a lot of places decided not to continue this. In Minnesota, we decided that it was valuable enough that we would find a way to really make it work. So, we've got this incredible surveillance system that we operate with a very low budget.

The goals of this system are to essentially explain the unexplained, and what I 01:17:00mean by that is there are people who die outside of the healthcare facility, and may receive an autopsy, so we partner with medical examiners to conduct infectious disease testing when there is a reason to suspect that the death that is otherwise unexplained might have been caused by an infectious disease. We run a panel of different tests to try to identify pathogens, and this information is really helpful for both understanding causes of disease, but also identify emerging pathogens, pathogens that we might not have thought to look for in Minnesota, because they're not endemic here, and it's also useful, because it 01:18:00provides information for the medical examiners to be able to better report the cause of death.

Q: So--you do have a population that does move a lot, I think those are called snowbirds, and they have a tendency to move south in the wintertime, and then come back, and maybe they're bringing back with them pathogens that probably aren't Minnesotan ones.

FIRESTONE: Yeah, that's certainly possible, and you know, any time people travel there's the possibility that they might bring back a disease that isn't endemic here. There is a lot of use for those purposes. With this surveillance system, when COVID-19 first emerged in Minnesota, the UNEX surveillance system expanded 01:19:00and started doing testing for people who might not have received an autopsy, but there was reason to believe that they might have had an infectious disease death, and so we expanded this program to not just be with medical examiners, but to also partner with funeral homes to do swabbing and testing those swabs.

The UNEX program has identified a lot of infectious diseases that might have otherwise been missed in Minnesota, such as cases of Legionnaire's disease that we didn't know the person had Legionnaire's disease and that might have contributed to their death. But then, with COVID, we were actually able to test people who hadn't received a COVID test and see if COVID might have been a factor in their death.

This actually led to a reduction in underreporting of COVID deaths in Minnesota. 01:20:00I reviewed the UNEX data and learned that once they began doing the funeral swabs, which was pretty early in the pandemic, we actually identified, two percent of the total cases that we identified that were COVID-19 deaths in Minnesota were actually identified through this system. So that's a huge number that would have gone missed as COVID-19 deaths if we did not have this system.

Q: You guys have this system, but not a lot of other people, not a lot of other states do? And this goes back, you have a database that goes back to 1995. That's incredible.

FIRESTONE: Yeah.

Q: That's an incredible tool.

FIRESTONE: It's an incredible resource, and you know, sometimes people might 01:21:00have had an infectious disease when they died, but that wasn't necessarily the cause of their death, and we see that a lot with COVID. We're strategic in which ones we actually test, if there was a clear injury death, we might not test for infectious diseases unless we thought it was related somehow. But it's a pretty incredible system, and it's a really small team that does this, there's a lot of student workers that help, and the information that we get from it is pretty incredible, and we've identified a lot of infectious diseases that we haven't seen in Minnesota otherwise through it.

Q: Okay, so your latest deployment, which I think you just returned to just like, weeks ago.

FIRESTONE: Yeah, so my most recent deployment was to Palau, to help with the 01:22:00COVID response there. That was a really fascinating deployment, and--

Q: When were you deployed?

FIRESTONE: I was deployed February fourth through the twenty-second.

Q: That's 2022?

FIRESTONE: Yes.

Q: Okay.

FIRESTONE: So, February 4 was a Friday, that Monday I was asked if I was available to leave for Palau on Friday. That Monday was kind of a fascinating morning. I woke up, let my dog out, and realized she was eating something in the backyard. I ran outside, it's like ten degrees out, I run outside in like, no shoes on, nothing, like in a tank top, very, very cold, and reach into her mouth and grab what's in there, and then realize it's a mouse head. I am not good with 01:23:00disgusting things like that, so I ran up, woke my partner up, and said, "I need you to clean up the mouse head that our dog just tried to eat." He wakes up, cleans up the mouse head, and then gets ready for his day and goes about.

An hour later, I run into his office, because he's working from home right now too, he's on a call, and so I sort of interrupted the call, and I was like, "Do you mind if I go to Palau on Friday?" He was like, "Go to Palau," and then he was like, "I got to get back to this call." By like nine a.m., I had been asked to go on this deployment, and so by noon, I was in the process of getting everything in order to leave on Friday. Palau is very far, it's in the northern Pacific Ocean, and there is only two flights in and out right now during, since 01:24:00COVID started, so it's very limited flights.

The reason I had to leave on Friday was to be able to make sure that I could make it in time for the Sunday night flight. When you fly to Palau, you cross the International Date Line, and so you lose a day, essentially, so I needed to leave on Friday so that I could arrive on Sunday, or by Sunday, to be able to take this Sunday night flight and actually make it in, otherwise if I missed it, I wouldn't be able to go until the next Thursday. So that was sort of an interesting part of this, because it wasn't like there were multiple flights, like you had to go right away if you were going to go.

The goals of this mission were to help Palau establish a COVID testing strategy, 01:25:00and then help run the community testing site that they created. Palau didn't have any COVID cases until August of 2021, and then that, those cases were identified in travelers, so they didn't actually have any transmission of COVID-19 within the country until December of 2021. But then--

Q: Did they have vaccine?

FIRESTONE: Yeah, they had a highly vaccinated population.

Q: Okay.

FIRESTONE: They are still working on providing boosters for the population, so not everyone is boosted, but the population itself that received the two doses of the primary series was pretty, was very high. So, after the first cases of domestic transmission began occurring, Palau had a huge case rate, it was the highest in the world for some of the time, and it's a really small population, 01:26:00it's about 18,000 people that live across the islands of the Palau nation. It was a huge number of COVID cases happening in this small population. There was a team from CDC that had gone a little bit before us, and really helped them design a testing strategy, and set up the testing site. So when we got there, our role was really to assist at the testing site, and provide recommendations based on sort of what we were seeing to the testing strategy and both the operation of the testing site.

We spent most of our time at the hospital in Palau, so it's in Koror, Palau, which is the most populous state in Palau.

Q: Now there are many islands, how did you get around on--did you go to all the islands?

FIRESTONE: There are a lot of islands, and not all of them are inhabited. So, we did end up going to one of the smaller islands and assisting one day there. We went to Peleliu, which for anyone who is a World War II history buff, that is a very, there was a very important battle in World War II that occurred there, it was one of the deadliest battles in World War II that occurred there.

Q: What was the name of the place?

FIRESTONE: Peleliu.

Q: You're going to have to spell that later.

FIRESTONE: Thanks for not making me spell it now. I'm a very visual person, so doing an oral history is a challenge in and of itself for me.

Q: Because Palau is right to the left of the Philippines, right, and Indonesia, in the waters around that area? Or it's in the Philippines Sea.

FIRESTONE: Yeah, it's right around the Philippines, so the Philippines are pretty close. So, we had flew through Guam to get there. Because most of the 01:28:00flights go through Guam. So--

Q: Which is south of the Marianas?

FIRESTONE: Yeah, I have to look at a map again. Yeah, it's very far. Because most of the population is in Koror, that's where the hospital is, and most of the businesses, and that kind of thing, are there. That's where the COVID, the community testing site was set up, was right at the hospital there. When we did go to Peleliu, we took a boat to get there, which was a really fascinating experience. It was really, so when we went to Peleliu, the primary goal was to provide noncommunicable disease care to the residents of Peleliu. But because there was so much widespread COVID transmission across the nation at this time, 01:29:00we were doing COVID testing before they could go and see the primary care providers for medication updates and managing other chronic disease conditions. Or injuries, there were a few injuries that came through, too.

If a person tested positive, they were still able to see a healthcare provider, but then the healthcare provider knew that they needed to be in full PPE rather than sort of just the N95 and eye protection. That was sort of our primary goal was to really help with that regard, so that people could get care for non-COVID conditions. While we were there, there was a person that was identified to need more urgent medical care, and so the person actually rode back on the boat with us to Koror, so that they could go and get hospital care.

Q: There's not that many islands with people on them, so in order for them to get this treatment or care, they've got to go back to like, what we would call like, the main island, or Koror?

FIRESTONE: Yeah, so--so they're--oh sorry, go ahead.

Q: No, I was just, it's a spread-out kind of, being able to see all those people, have them come to you, how long does it take to get from one end of the island to the other, and for them to come to see you? I mean that's got to be, that can't be, I don't know, a couple hours, or does it take a day? Is it easy for you to get around the island? Are people moving around fast enough? Are there bridges?

FIRESTONE: So, there are bridges between some of the islands, but a lot of the movement between islands occurs via boat. Within the islands, people have cars 01:31:00as well, so they can go around within an island that way. Some of the other islands do have community health centers, but they might not have a doctor there. But they might be a nurse that's providing care there. In Peleliu, they have this really great new facility for medical care, and right next to it is a house, and that's where the nurse lives, so if somebody needs emergency care in the middle of the night, the nurse can provide it. But if they need to see a doctor, or there's something that the nurse, some sort of service that the nurse can't provide, then they would need to go to the hospital, and most of that, I believe, happens by boat, but I believe there is some flights between islands, 01:32:00depending on the island, as well.

Q: So, this one case came in on a traveler, and then additional cases weren't detected until a couple months later, and then transmission began to occur throughout the whole island, a high transmission rate, you said. And these were among vaccinated people, or not among vaccinated people?

FIRESTONE: A little bit of both. Some people were unvaccinated, but there was a really high proportion of the population that was vaccinated. We, one of the things we also did while we were there was look at the characteristics of hospitalized patients, and one of the things that we saw that was a common trend among hospitalized patients was that people were either unvaccinated or had received the vaccine, both series of the--or both doses of the vaccine, but had not been boosted, and they might have received both doses a year or more prior 01:33:00to testing positive for COVID. This told us that it was really important that Palau make sure that they are increasing the number of people that not only got a COVID vaccine, the primary series, but also got a booster.

Q: You said it felt like the early days of the pandemic in some ways.

FIRESTONE: Yeah, so it felt sort of like some of the early days of the pandemic, because the people of Palau hadn't experienced this so far. This was new to them, so things that we had sort of experienced in March of 2020 were new to them in December of 2021, January of 2022. A lot of people were just getting used to wearing masks everywhere, and the doctors were just starting to have 01:34:00their first COVID patients, and so they were really looking to learn from people who had been caring for COVID patients for a long time.

They had done a lot of preparation, a lot of research on the types of treatment, and that kind of thing. But preparing is different than sometimes experiencing it for the first time. What we were sort of hearing from people was just how different this is, how they're trying to make sure they're really protecting their patients, and really just sort of going through this for the first time, and sort of dealing with some of the mental health toll of it for the first time, too.

Q: Were the facilities overwhelmed, like they were here in the United States?

FIRESTONE: The facilities were not overwhelmed while we were there, but the concern was that they easily could be. Part of the, what was established as the testing strategy, so that the healthcare system wouldn't be overwhelmed, was that they created a community care center for COVID. So if you tested positive for COVID, you would then go and see doctors and nurses in this care center right away, because this would have been people who were not sick enough to need to be hospitalized right away, so they were people that could easily go home after this. But what they would do is, they would assess their other medical conditions, and look at their age and how they were doing that particular day. 01:36:00They might provide COVID treatment right there for them to prevent them from needing hospitalization later on.

Q: What they're using is the lessons learned from people a year ago.

FIRESTONE: Yeah, so that was a way to try to prevent hospitalization so that the healthcare system wouldn't be overwhelmed, so they wouldn't experience what other facilities had experienced, of these rapid increases and limited resources to provide care.

Q: Is that outbreak sort of tamped down, or in control now?

FIRESTONE: Cases started going down quite a bit while we were there, and it had just spread so rapidly that it wasn't surprising that it started to decrease while we were there, because so many people had already gotten it by then.

Q: Those were vaccine, sorry, people who had been vaccinated, did they have the 01:37:00same kind of, you know, reaction, like it was like a mild flu, or was it like what we saw over here too, just everybody's different and they all reacted differently to it?

FIRESTONE: Yeah, so most of the people that we saw come through the community testing site were experiencing relatively mild symptoms, but we didn't do an assessment of what symptoms people were experiencing, it was sort of just anecdotal of what people were telling us as they were coming through the testing site. It's also possible that there were people who were very sick at home, and were not getting tested, and we just don't know, just like in the U.S.

Q: Was it easy for them to come in and get access to the healthcare system? It wasn't a very long drive, it was just, there wasn't anybody missing that could, out in the hinterlands perhaps.

FIRESTONE: For the most part, because most of the population is in sort of the area where the hospital is, for people around there it was relatively easy to be able to come in and get testing. For some of the more rural areas, they did do community testing at certain times for those areas as well, so that people wouldn't have to travel down, but they could get tested and get treatment at their home site, if needed. That was also part of it too, we just weren't part of that as much.

Q: This was your second actual deployment to another site, can you compare it to the first one, what was it--well obviously, it's a lot different. But you're working with more people in the field, you're encountering more people probably at the ministries of health, how are you interacting there? How did it-- were 01:39:00you constantly working all the time, or did you have time to explore the area you were in?

FIRESTONE: This was my third deployment, but my first international one. Palau is a Freely Associated State, which means that they are an independent nation, but they receive certain supports from the U.S., so everyone spoke English, and Palauan as well. That was great because there wasn't really a language barrier that we were working with. We were working every single day, except that we did have one day where we were able to explore a little bit, and that was a really great experience, because one of the things all the people that were working with us kept telling us was oh, you've got to see Palau while you're here, it's 01:40:00a weird time, we're experiencing COVID, but there are certain things you have to see while you're here. There was just this pride of people of we love our country, we want our visitors to love our country, too.

Everyone kept telling us we had to go to the Rock Islands, which when you Google Palau, that's usually what comes up is a picture of the Rock Islands. It's these islands that are, nobody really lives on them, but it's some of the most pristine water around them, it's incredible scuba diving and snorkeling, and it's one of the biggest scuba diving destinations in the world because of how incredibly beautiful it is. One of the things that's there is this lake that was originally part of the ocean, but as the Rock Islands began developing, this one 01:41:00section of water got isolated from the rest of the ocean within the land borders of the Rock Islands, and there were jellyfish that were caught in there when this happened.

Over time, because they've had no natural predators, the jellyfish have evolved not to sting, so you can actually go and swim with these jellyfish that don't sting, and so that was sort of our one big thing that we were able to do in our brief time off. It was--

Q: How big are these jellyfish?

FIRESTONE: They're normal-sized jellyfish, like--

Q: Like man-o-war type jellyfish, type?

FIRESTONE: I'd say they were like, the size of a person's head, typically.

Q: Wow! They didn't sting you? That has got to be--

FIRESTONE: They didn't sting. They were everywhere, so you would unintentionally be bumping into them all the time, so you had to be gentle when you were 01:42:00swimming so that you wouldn't accidentally send one flying. That was a pretty incredible experience, and so because Palau is a big tourist destination, but there isn't a lot of tourism happening right now, especially because there were so many COVID cases while we were there. We were the only ones in this incredible location that used to have a hundred tour boats waiting every single day to get in.

Q: Wow.

FIRESTONE: Because we had actually gotten to be able to go and see the Rock Islands, it was a really nice way to sort of connect with the people that we were working with, because everyone loves the Rock Islands, and everyone really was encouraging us to go, so that was a really incredible experience. But in terms of sort of more similarities and differences with other deployments, I 01:43:00would say one of the most important things on a deployment is to really be a good partner for who you're working with, and so this came up a lot in Maine, because we were sort of assisting, we were asked by the health department to assist, and we were providing support and technical assistance, and working with them there.

It was similar in Palau, because we were there to help them, we weren't there to take over, they have a Ministry of Health, they have an emergency operations center, so we were there to sort of provide expertise more than run the show. That's just a really important thing to make sure you're not, you know, stepping on anybody's toes, or--and you're just working as a good partner to provide the 01:44:00help that you were asked for. That was a really nice part of being in Palau, was just being able to connect with the people that we were working with, they were telling us things about their culture, and sharing things with us, and there was a big sense of pride in being Palauan, and it was really an honor to be invited and be able to offer assistance.

Q: You were able to get to know the surrounding culture a little bit, rather than just go in, do a job, and leave. That's a much better way to collaborate.

FIRESTONE: It is.

Q: Yeah, so you were actually, I mean when you were swimming with those jellyfish, did you even think about the environmental health of your surroundings, and if these jellyfish, you know, do they get out of hand, would they, you know, I can just imagine what was going through your head while you're 01:45:00swimming with a thousand jellyfish.

FIRESTONE: Yeah, so we were really lucky to be able to swim with the jellyfish, because there had been so much tourism that it was actually harming the jellyfish population, and so the jellyfish lake was shut down for a few years to allow the population of jellyfish to rebuild and regrow. That was something we thought about a lot was just really being conscious of us coming into this incredible ecosystem and making sure that we weren't causing any damage to it.

Q: That's nice. Wow, we have talked a lot about everything, I wanted to ask you, you have an--how many more months do you have in this assignment, where you are now?

FIRESTONE: We have about, wait, [unclear], only about three and a half months left.

Q: Do you know where you're going afterwards?

FIRESTONE: I don't know where I'm going yet. But I am working on that.

Q: That is just so incredible, I mean you guys come in from a place of, I'll just do whatever I want, and then you'll find places, and it's incredible, because I guess the EIS has such a great background, and everybody wants you, because you've done so much in such little time.

FIRESTONE: Yeah.

Q: Given your unique knowledge and experience of this program, I'm going to think about future historians, and future researchers, and future EIS officers, what do you think they should know about what we're experiencing right now, for the future? Or not for the future, but what do you think they should know?

FIRESTONE: I think one of the things that I really hope for future generations is that we really take the lessons learned from this experience and continue to 01:47:00apply them in the future. Sometimes when we're not in crisis mode, it's really easy to kind of forget about what's happened in the past, and not use the knowledge we've built, and the experience we've had, to kind of learn to do better in the future. My hope is that this experience will be something that we will continue to learn from and continue to improve public health from it.

Q: As we turn towards your personal life, and reflections, COVID has really not separated your work life from your family life. I know you said that you have a partner that you live with, how has that, how has your mental health and the 01:48:00state of your home life weathered this situation, where you can navigate between this is my work life, this is my home life, but they're all in one room?

FIRESTONE: Yeah, so when the pandemic first started, we were in a one-bedroom apartment with no real doors except the front door, we only had sliding doors for the rest. We were both working in the same room, on opposite sides of the room, and trying to navigate that shifting dynamic of having meetings, trying not to get into each other's way with our meetings, so that we weren't hearing each other, and that kind of thing. I think that one of the hardest parts of that, other than just making sure we weren't, you know, talking over each other in meetings, was really having that separation between work and home. So, my 01:49:00partner in particular had a really hard time with that, where he would end up working much longer hours, because he wasn't trying to catch a bus to get home at a certain time.

He could just keep working and not even realize it. I had a lot of that as well during the beginning, where I was just working really long hours, because there was a lot of work, and there was a lot of need for it, and it was easy to do, because I was already home. Now, we have our own offices in our new place, where we have a little bit more separation between this is my office, and this is the rest of the house kind of thing, and that has made it a little bit easier to have some of that physical separation between work and home. But I think the biggest transition was just getting a pandemic puppy, and at 4:30 every day 01:50:00she's like, "Which one of you is taking me to the park? Let's go." So--

Q: Aww, that's great, great for your mental health!

FIRESTONE: It is really great for it, and she forces us out, even when it's like minus five degrees, which is really hard sometimes.

Q: There's that, too.

FIRESTONE: Yeah, so she's just this bundle of unconditional love that has reminded us that we need to have some separation between work and home.

Q: Do you think there's going to be nine to five jobs anymore?

FIRESTONE: You know, that's a good question! I haven't, I've thought a lot about how the work environment might shift with COVID, and you know, I think the pandemic has been so hard on mental health. But I think one thing that we have seen is that there are people who are thriving working from home, and having a little flexibility in their day, and so I do hope that we continue to have some 01:51:00more opportunities for this flexibility so that people can really do what works better for them, because I think if we all are able to do everything we need in our personal lives, including taking care of ourselves, having time to prepare food, having time to exercise, having time to spend time with our family, the outdoors, I think if we have those opportunities on sort of a schedule that works for us, then we're going to be better workers, too. If nothing else, I do hope that we have a little more flexibility in our day to be able to take advantage of that, and really be better both in our home and personal lives.

Q: Yeah, it's good to shift your brain to different things during the day. A couple of things. Your brother is still in Japan?

FIRESTONE: He is, and actually right before we jumped on this call, I got an alert from my dad, I got a text message from my dad, who is a news junkie, that he had just heard of a report of a really big earthquake in Japan, and he was like, "Don't worry, I already talked to your brother, he's okay, he just doesn't have power." Yeah, so my brother's been there since 2006, and he has three kids, my mom was living with him for a while too, she's back in the U.S. now, moved back during the pandemic. But yeah, so he, so this is the first big, really big earthquake since 2011, when there was the Fukushima nuclear disaster and tsunami, which I was actually in Japan visiting my brother during.

Q: Oh wow.

FIRESTONE: Yeah, so I was sort of feeling a lot of feelings about that 01:53:00earthquake, because my brother's going through not quite the same level as bad as that earthquake was, but he's sort of going to be dealing with that when he gets up, because he's not sure if the power's going to be back by the time he gets up. It happened in the middle of the night, this one, and so he went back to sleep and he was like, I'll let you know in the morning.

Q: Yeah, well it looks like the epicenter was right near Fukushima again.

FIRESTONE: Yeah, exactly.

Q: Yes. Were you worried about him during this pandemic? I know like, when you don't have your family together, you want them all to be in one place when there's something that's so large like this. Was it hard to keep up with him, and--?

FIRESTONE: Yeah. My brother and I are really good at keeping in touch, we talk every single day via text message, at minimum, and so we've been used to it being hard to communicate, so we'll have conversations over multiple days 01:54:00because of the time difference. Actually, one of the nice things about being in Palau was that we were actually in the same time zone, so I could talk to my brother during like, normal times, and not early in the day, or late in the day for one of us. So that was sort of a nice bonus, just to be in the same time zone as him.

But I would say that the hardest part of this pandemic for me personally has not been being able to go and visit my brother. And my mom was there for a while too, so visiting her as well. But my, because of the timeline of the EIS, we have to defend our dissertation by the end of March, but then we don't start working until July, so my plan was to go and spend a month with my brother before starting EIS, but that was the peak period that everything was shut down, 01:55:00and the main reason that I wanted to go and stay with him is because he has two children, and then he had a third one born right at the beginning of the pandemic. I had actually been able to be in Japan when his second baby was born, and so the timing was looking really good for me to be able to be there for the third baby being born as well, but the pandemic halted that.

He has two girls, they're the older ones, and his son, I have not met in person yet, because he was born in June of 2020, and so I love my nieces so, so much, and have such a great time when I'm with them, and I of course love my nephew too, but it's broken my heart to not be able to actually meet him in person so far.

Q: Oh, he's probably like up and crawling, and getting around by now.

FIRESTONE: Oh yeah, he's talking, and walking, and yeah. He's a big kid now.

Q: Wow. Wow! I'm sorry about that, wow.

FIRESTONE: Yeah, so that's been really hard, and we were thinking that there was going to be an opportunity to go for Christmas, because COVID numbers were looking better, more people were vaccinated, and then Omicron hit, so.

Q: Yeah. Sure did.

FIRESTONE: I'm hoping. Yeah, so we'll see. I'm hoping maybe this summer, there will be an opportunity for me to go, because my nieces are getting older, too.

Q: Yeah! How old are they?

FIRESTONE: They're seven and five, and their birthday are this summer, so I'm hoping to be able to go for their birthdays.

Q: It would be nice-- I hope you do go. We come to the end of this, and there's so much more I'd like to explore with you, but we've been on the call for about two hours now, I'm sorry it's taken so long, but you have a lot to say, and I wanted to get it in there, and if you do want to follow up, it would be nice to 01:57:00hear from you. I do want to do this, like in like three or four years, and see how people have advanced along. I just wanted to ask, is there anything that we haven't covered in this part that you'd like to share before we stop the recording?

FIRESTONE: I think if I could share just a piece of advice for future EIS officers, one thing I would say is to really keep an open mind, EIS is such an incredible time to really explore new things, to meet new people, and to learn about things that you might not have otherwise been exposed to and might actually really discover that you love being a part of. My advice to future EIS officers would be to keep an open mind and take advantage of all the opportunities that come your way.

Q: Thank you, I'm going to stop the recording.

FIRESTONE: Okay.

[END OF INTERVIEW]