Amber Kunkel

Q: Today is Friday, April 29, 2022. This is Mary Hilpertshauser for the COVID-19 Oral History and Memory Archive Project. I'm in Atlanta, Georgia and I will be talking with Amber Kunkel who is in Atlanta, Georgia as well. We are recording through Zoom, and we've had one pre-interview. Amber, do I have your permission to interview you and record this session?

KUNKEL: Yes.

Q: Thank you. For the record, can I ask you to state your name?

KUNKEL: It's Amber Kunkel.

Q: Can you tell me what your current position is with the CDC [Centers for Disease Control and Prevention]?

KUNKEL: I'm an EIS [Epidemic Intelligence Service] officer--an Epidemic Intelligence Service officer--with the Poxvirus, and Rabies Branch.

Q: All right, thank you for being with me here today and being part of the project. Before we go into the details of your path to CDC and COVID-19 [Coronavirus disease 2019], could you tell me a little bit about your family background and the community where you grew up?

KUNKEL: Sure. I was born in Chicago and lived there until I was about eight years old. My family moved to Richmond, Virginia. I'm the oldest of four kids total which was sort of a great experience growing up and having lots of siblings around. I think one thing that was significant in my kind of childhood and family background is that I had some relatives on my dad's side of the family in particular who were very interested in social justice when I was growing up, including a great aunt who I'm very close with still who was a Catholic sister--a Sister of Providence--and was really involved in promoting nonviolence and activism and that sort of thing. I think I always had some of 00:01:00that--those interests and thinking about the ways that I am privileged in my life and then having a responsibility to give back because of that I think was something that I got from my family and also growing up in a Catholic family that was interested on the social justice side of that religion.

Q: Could you talk about where you went to school? College?

KUNKEL: Growing up I went to public schools in Richmond, Virginia including some magnet schools which I think was a really great experience and got me to be challenged academically already by the time I was in high school. I started taking some challenging math and science classes. When I was really young, I 00:02:00always thought that I was going to be like a writer or do something in the humanities and it wasn't until I got to high school that I started realizing that I was interested in math and science and that I had some skill in that area as well. By the time I went to college--I went to Rice University in Houston, Texas--and I knew that I wanted to do something that was related to probably biology or healthcare and also math. Started out thinking I would do like a biomedical engineering but found that being in the lab wasn't really for me and I was a lot more interested in some of the math classes and math modeling and they also had a global health technologies track as a minor that I did as well. I started doing that combination of things--the mathematics but also the global 00:03:00health--which is part of what lead me to epidemiology. Actually, when I was in high school, there was this scholarship competition at the time--it was called the Young Epidemiology Scholars Competition. I think CDC was somehow involved--a sponsor or something--of this. I had just found it online when I was looking for scholarships and I had never heard of epidemiology before, but they had some nice online resources about what epidemiology was. Then to compete in the scholarship competition you had to do a research project and you could either do something where you're collecting your own data and kind of a full experiment in that sense, or they provided some data sets online that you could just work with and do some analyses. I just kind of did that on my own time the summer before my senior year in high school and put together a project--I think it was related 00:04:00to binge drinking in teenagers or something--and submitted it to this scholarship competition. Then ended up getting sort of a regional finalist award for that which allowed me to go to basically a conference they had with all of the regional finalists from around the U.S. We could see each other's presentations and hear from real epidemiologists and that was I think a really eye-opening experience and gave me that seed of the idea that maybe I would want to go into epidemiology eventually. I think I always had that in the back of my mind during my undergraduate career and saw that it's a possibility but there wasn't a chance to major in public health or epidemiology or anything like that. I had that idea in mind and then by the time I was graduating from undergrad I 00:05:00had some different research experiences combining both the global health technology aspect and the math aspect and thought that epidemiology seemed like an interesting way to continue doing that in the future and particularly on the infectious disease side.

I think the appeal of infectious diseases for me is that--well, sort of two-fold--I think on the social justice side I had learned that there's real disparities in how people are affected by infectious diseases across the world and also like we've seen with COVID within the U.S. as well. I was interested in working on these diseases where oftentimes we have good tools available--good treatments, or vaccines, or that sort of thing--but the challenges are related 00:06:00to access. Then on the mathematical side I think infectious diseases are really interesting because they have these kinds of non-linear dynamics and what happens to you affects what happens to your neighbor and so you can get these crazy curves and things coming out and you can get dynamics that you wouldn't necessarily expect where you need some mathematical tools to help you tease them apart.

Q: That conference where you attended for the scholarship--did you meet anyone there that influenced you or helped you solve this idea of epidemiology?

KUNKEL: I don't really remember anybody who I met to be honest.

Q: That's fine. Were you in high school at this time or was this in college? This is high school, OK?.

KUNKEL: Yes.

Q: All right. Then after that and you're at Rice, were you involved in any 00:07:00social justice programs outside of school or was it all just school with that underlining tone of thought?

KUNKEL: It was mostly school related. I -- one summer participated in this program that was called Engineering World Health and it was two months. I think we spent the first month in Costa Rica learning about--both doing some Spanish classes but then also there were some hands-on practical work on learning how to repair basic medical equipment. Then spent another month in Honduras based at a hospital kind of as an assistant to the people who were doing the equipment maintenance and repair there. That was a really interesting experience and a 00:08:00chance to work in an international setting for a little bit. It was also clear that I did not have a lot of skills that I was really bringing to the table there. I think it was probably more of a learning experience for me than it really was me assisting. I think that's often the case earlier in your career in particular. For me that's been something that has motivated me to keep getting more education and learning more and trying to come to a point where I feel like I really do have something to contribute and that I can bring to the table to help other people as well.

Q: What were the skills that you thought you were missing?

KUNKEL: I mean, in this case, where we were trying to repair medical equipment, it was--I was clearly not an expert in that. I'd had a month of training and 00:09:00that's not really enough for a lot of the problems that they were facing. I think you could take that any sort of way. In a broader sense the skills that I've been mainly focusing on in my career are--a lot of them are data related. Modeling and data analysis and data management and that sort of thing. Other epidemiology skills like study design and also implementation of doing different research projects. Just wanting to feel like I'm able to be an expert in my field and have that to contribute.

Q: What was the medical equipment you were repairing?

KUNKEL: Things like a pulse oximeter, even like basic blood pressure cuffs or 00:10:00some larger machines as well. Mostly kind of basic things.

Q: Okay. Well let's move on to your post-doc--

KUNKEL: PhD?

Q: --PhD, thank you. Let's move on to your PhD before you become a post-doc. Yes, so you started at Harvard [University]. How did you get into Harvard?

KUNKEL: I don't know.

Q: You are incredibly talented or--how did that come about? Did you want to go to Harvard?

KUNKEL: Yes, so--I had applied to I think maybe five or six graduate schools and only two of them I think were in epidemiology and one of those was Harvard. I was coming from--at Rice the--so my major was called Computational and Applied Mathematics, and this was in the Engineering school. I think I had kind of the 00:11:00mindset of doing a PhD that you might get in an engineering school which is that--my advisors told me a PhD you should--if you want to do it, do it as soon as possible, do it as fast as possible, and get it over with, basically. That was the mindset that I had going into it. I knew that I wanted to do infectious disease modeling, that I wanted to be doing differential equation models or agent-based models--different types of models and then using those to look at the effects of different interventions and trying to optimize our response to different infectious diseases. Actually, about half the programs that I applied to were also in engineering schools and they were mainly like operations research, industrial engineering, that sort of thing. Then the other half were in epidemiology and Harvard was one of those. I think the main way that I got 00:12:00into Harvard was having this really strong math background and I'd been doing mathematical modeling--honestly starting as kind of like a hobby in high school and then throughout college as well. I think I had some really strong quantitative skills that I was bringing to the table and had done research related to that as well and I think that that's probably how I got in.

Q: Okay, could you--you keep saying mathematical modeling. Could you give an example of what that would look like or how that could be used in public health?

KUNKEL: Yes, mathematical modeling can mean a lot of things. Usually when we're talking about it in the infectious disease standpoint we're talking about kind of a mechanistic modeling where you're making this really over-simplified version of the world using mathematical equations. You're thinking about, for an 00:13:00infectious disease, for example--some of the really basic models that we use are called SIR which stands for Susceptible, Infectious, and then Recovered. You can think about people who are in the world belonging to one of those three classes when we're talking about a specific infectious disease. Either you're susceptible to the disease, you're currently infected and you're infectious to other people, and then you're recovered and for a number of diseases like measles, once you're recovered then you're immune so you're not going to get it again. You can think about the contacts that we come into with each other on a normal day that if you have a person who is infectious who comes into contact with a person who's susceptible then that can lead to the person who's susceptible becoming infectious as well. Then you have 00:14:00these two people who are infectious and then they're coming into contact with people and so then you can see these--kind of like exponential spread of infectious diseases. You can draw diagrams of that, or you can imagine a movie of that but then another way that you can describe that is using a series of mathematical equations and then by using the equations it allows us to run that film forward basically and see what's going to happen over time and it also allows us to say well what if we do some kind of intervention. For example, what if we're talking about measles--what if we vaccinate a whole bunch of the population and so then we're moving them from susceptible into this--essentially into the recovered component where they've not actually been sick but they've been exposed to the pathogen and so they're no longer susceptible to it. You can compare what would happen in these two theoretical populations--one where people are not vaccinated and one where they are--and you can use that to provide an 00:15:00evidence base for how effective these interventions could be against the disease.

Q: So, you have quantifiable data?

KUNKEL: Yes, but a lot of the times these models are--they're different from statistical models where you are kind of basing it completely on the data and then trying to describe what that is. With the mechanistic models it's based somewhat on data but also somewhat on kind of an understanding of the disease process. The data will come in as the parameters for the model, so for example like how many people does one person come into contact with every day. Then you'll put those as as inputs and then you can see what the output would be, and you can compare the output to surveillance data or something and try and make sure that it's working correctly and then adjust your parameters accordingly. 00:16:00You also can consider like really theoretical scenarios. Like, during my PhD I worked on tuberculosis and that's a really slow-moving disease so a lot of the times when you're modeling, you'd be modeling what would happen over the next twenty years if we decided to implement this treatment for tuberculosis, for example. That's something that we can't really do a study right now to see what would happen because it would just take too long for us to get any useful information. Instead, we're trying to borrow information from how we know the disease spreads and use that to make inferences that we can't actually observe in the real world in the kind of time that we want to make decisions.

Q: It's like future planning? A road map?

KUNKEL: Often, yes.

Q: A possible future? Could you tell me more about your time at Harvard? We spoke earlier and you actually went to Harvard and Yale [University].

KUNKEL: Yes, so the way the doctoral program worked at Harvard when I was there was that you spend--like the first two years mainly doing classes and then also doing some research on the side and then after that you take qualifying exams and then you focus just on research. I was working with my doctoral advisor--his name Ted Cohen--and he works on tuberculosis and particularly on drug-resistant tuberculosis which is a really interesting topic. Towards the end of my second year, he got a job offer at Yale and decided to move down there. I had to decide if I was going to stay at Harvard or if I was going to move to Yale also. What we ended up deciding was that I would stay kind of enrolled officially at Harvard and that's where I got my degree from but I moved down physically to Yale so I could keep working with my advisor. I spent two years living in New 00:18:00Haven and I think the benefit of that was that it allowed me to expand my network and I got to know people at the Yale School of Public Health as well. I think that the downside was that I was not as connected with the Harvard community and with all the research going on there as I might have been otherwise.

Q: Could you talk a little bit more about what you were working on besides--you were working tuberculosis but what was the other research that you were doing at that time?

KUNKEL: I mostly started from tuberculosis or tuberculosis was sort of the motivation but then within TB [tuberculosis] I got interested in particularly preventive therapy for TB. People can take TB drugs to prevent them from getting TB disease in the future, essentially, but there's some concerns about whether 00:19:00that could lead to an increase in multi-drug resistant TB since the drugs that people were taking to prevent TB were the same as the drugs that they would use to treat TB if they eventually got it. I did a few different projects that were related to that and then I got interested in thinking sort of from a more theoretical perspective--well, TB is not the only disease that has preventive treatment available. There's also malaria, there's also HIV [human immunodeficiency virus], there's many things out there. I did some modeling that was kind of on the more theoretical side that was saying well if we just know that we have a preventive therapy what are the different ways that it could affect the amount of drug resistance that we have in the community and what are the conditions under which we might expect the drug resistance to increase, or 00:20:00decrease, or follow some kind of non-linear dynamic. Then I also had some opportunities come up as I was thinking about those questions to work on--some other diseases. There were a few people at Yale who had done a modeling paper that was proposing the idea of using antimicrobial prophylaxis for cholera in UN [United Nations] Peacekeepers. The motivation for that was the big cholera epidemic that had happened in Haiti following the earthquake that was ultimately traced to UN Peacekeepers who had come in and brought the disease into the country. They had proposed that it might be a good idea to give anyone who's a UN Peacekeeper going to a different country a short course of antimicrobials to prevent them from bringing cholera into another country. Then one of the 00:21:00concerns coming up following that paper was, well, what would happen to drug resistance. I led a follow-on modeling analysis to look at whether we thought that there would be significant increases in drug resistance or not following that. It was just I think another example of this sort of category of prophylaxis or preventive therapy that, in this case, didn't lead to any sort of policy change but I think in other cases that potential is there.

Q: Okay, your degree was awarded in 2016, and after that was awarded what were you looking to do?

KUNKEL: Towards the end of my PhD, I think I was realizing that I was spending a 00:22:00lot of time in front of the computer every day and I was getting a little bit tired of that. It was also a lot of work that was pretty solo driven. I would have people who I would consult with on my models, but it was mainly me driving them forward and I really like working with people and I wanted to move into a role that had more of that kind of component to it. I also was finding it frustrating--you had asked about data earlier--and as I had said, a lot of these models are actually not based on a whole lot of data. The problem is, though, that they have these parameters that go into them and then if you change the parameter only a little bit then the dynamics that you're predicting--they can also change a whole lot. It's really important to know all of these data points that you're using to parameterize your model and I felt like for a lot of 00:23:00diseases that data is really lacking--both the kind of mechanistic data and then any sort of surveillance data where you can match what your model is predicting with the real world to see if it seems consistent with what you would expect or not. I think that combination of wanting to work with people and then also wanting to be more involved in the generation of data led me to think about wanting to do something different after my PhD and I looked at kind of a range of possibilities. I actually had applied to the EIS program here at CDC as one of the different things that I was looking at and at the time I ended up being wait-listed and so I didn't get into the program. It kind of turned out to be a good thing because around the same time I got a job offer from--a position with the Pasteur Institute and it was based in France but then would involve working 00:24:00with various --different countries on some different infectious disease projects. That's what I ended up doing instead was going to Pasteur and I did a three-year post-doc with them working in France and then particularly in Cambodia and also in some other countries as well.

Q: You left the United States and moved to France. Where in France were you? In Paris?

KUNKEL: Yes, this is a Pasteur Institute in Paris.

Q: Okay and so you stayed in Paris or--what was the project that you were working on?

KUNKEL: When I started at--when I got offered this post-doc essentially, they had told me that the person who they had originally planned on supervising the project had just accepted another job offer. They had the funding for the position for three years, but they didn't really have a project anymore that it 00:25:00would be doing. They said the supervisor for the position-- Arnaud Fontanet in Paris--said, "We have collaborations with people in different countries and we can see if some of them might be interested in hosting you for a bit and you can go work with them for a few months and then if you get on well with them then maybe you can do some projects with them." I thought that sounded like kind of an interesting idea. I was excited about the idea of being in France and excited about the idea of traveling to some other countries and so I thought I would give that a shot. I arrived in France and had to stay there for a while to get visa issues sorted and that kind of thing. Then as soon as I was able to travel, I went to Cambodia to the Institute Pasteur of Cambodia. The head of the epidemiology unit there at the time was named Patrice Piola and he was 00:26:00relatively new, so he had just started applying for some grants to work on malaria in Cambodia. I stayed there for a couple months and helped with some of the grant applications, and we got on really well. A couple months later when he started receiving some of these grants then he invited me to come back to Cambodia and work on them with him. That was the main thing that I did during my post-doc. There were also other projects going on at the same time. When I started, for example, they were--the Paris team was planning on doing sero-survey [serological survey] for Zika. This was already 2017 so it was a couple of years I think after the big Zika pandemic wave. There are some 00:27:00questions about how much Zika was present in different countries in Africa and in Asia and so they wanted to do a sero-survey in a few different countries in Africa and Asia and see how much serological evidence there was of people having been infected with Zika in the past. I worked on that some--coming up with a protocol and working with the sites to figure out what that would look like practically. Another thing--Patrice, before being in Cambodia had previously been in Madagascar and still had some data sets remaining that needed some help, so I worked on those as well--particularly one that was related to induced abortions and trying to tell what the frequency of those are in Madagascar. I got a chance to get a few different flavors of projects along the way.

Q: Couple of questions--why Cambodia? What made you choose Cambodia when they said look around and see what projects you would like to work on?

KUNKEL: I think it was mainly the relationship between the two supervisors. My mentor in Paris knew Patrice well and he was open to me going there. I think if it hadn't worked out then maybe I would have gone somewhere else.

Q: What was it like to work with Patrice? What was that relationship like? Can you example of how you worked together so well?

KUNKEL: Yes, I mean, I loved working with Patrice. I think he was somebody who has a lot of ideas and that's always kind of a fun dynamic for me, I think, is to work with someone who has a lot of ideas and then I think I tend to be kind 00:29:00of more practical sometimes into implementation and how do we make that work. I think that can be a good pairing. I also think I felt like Patrice was just really generous as a mentor in terms of spending a lot of time with me and talking to me about how things worked and how things worked in Cambodia. Things about the system that were good and things that were not so good. I think he wasn't shy, for example, about pointing out some of the holdovers of the colonial past. There are definitely still some disparities--really significant disparities--in terms of pay between the international researchers and then the Cambodian researchers who are working at the same institution. In terms of the educational opportunities that were available to me versus my Cambodian colleagues. I appreciated that he was really aware of that and advocating to 00:30:00change things and then also made me aware of that as well. That was another thing I appreciated.

Q: How did people respond to you coming into their country?

KUNKEL: I had great relationships I think with everyone who I met. I think it probably depends on having the right attitude and I think I came in with I think a certain degree of humility and just interest in learning and more interested in seeing what would happen to these projects rather than making sure that I would be first author or trying to make a name for myself. I think having that humility I guess is important. I really had a wonderful time with the people I worked with in Cambodia.

Q: You were working at--Cambodia for how many years? Or did you go back and 00:31:00forth from Paris to--where in Cambodia were you?

KUNKEL: At Pasteur they had kind of a rule that you weren't supposed to stay for more than three months out of the country at a time. I was traveling back and forth a lot. My first year maybe I spent four months or something in Cambodia and then it kind of gradually increased until my last year I think I spent maybe nine or ten months out of the year in Cambodia. There are always these flights back and forth.

Q: Where in Cambodia were you?

KUNKEL: Mainly in Phnom Penh and then our projects were based in forested areas in some of the different provinces Mondulkiri Province in particular.

Q: You're working on malaria control and Zika work or was it just malaria control?

KUNKEL: Almost entirely the malaria work.

Q: That was for the rapid diagnostic tests?

KUNKEL: The main thing that was inspiring the malaria work--the projects that Patrice was working on--was kind of an understanding of the geographical distribution of malaria in Cambodia. Malaria in Cambodia is very different from malaria in Africa. In Africa we know it's mainly young children who are affected. In Cambodia it's mainly adult men. The reason for that is that malaria in Cambodia is almost found pretty much exclusively within forested environments. It's basically an occupational disease--so it's people who go into the forest for work, whether that's logging, or fishing, or that type of thing--were then exposed to the vectors that are carrying malaria and that's where the transmission cycle is continued within Cambodia. The idea that Patrice 00:33:00had-- Patrice was a former MSF [Médecins Sans Frontières] so he really liked to be in the field and working in challenging environments. He thought that it was sort of a problem that we knew that malaria was being transmitted inside the forest, but all the interventions were happening outside the forest. All of the health centers outside of the forests there's village malaria workers in Cambodia who are like community health workers who are working on malaria control, but they're located in villages, they're not located inside the forest. His idea was that we should train people who are used to working in the forest environment in malaria diagnosis and control. The projects that we were working on we trained some of these people who had this background of working in the 00:34:00forest and then equipped them with smart phones that would both track where they were so we could see where they were in the forest and also had data collection tools so anybody who they met they would ask them a lot of questions about if they'd had malaria and also about the different control measures that they were taking. They would also be able to take a sample to see if they had malaria or not and then in some cases were able to do the rapid diagnostic tests and if necessary, give treatment. That was a main focus of those studies and then we did do some work as well with the rapid diagnostic tests. While I was in Cambodia, malaria was dropping quite a bit which is great because there's a global goal to eliminate malaria from the Greater Mekong Subregion as soon as possible, basically. The reason for that being that that area is kind of like a 00:35:00hotbed of anti-malarial drug resistance so pretty much every time there's been resistance to anti-malarial drugs it's started somewhere around the Thai-Cambodian border. The solution to that is, well, if we don't have any malaria any more than that won't happen anymore. We were seeing really impressive advances in--towards malaria elimination while I was there but there was some concern that is this real or not. Is it possible that we're missing some of the malaria cases that the RDTs [rapid diagnostic tests] aren't working as well? I did a small surveillance study that was in a few different health centers where we looked at all of the people who were coming in to get tested for malaria and we asked them not only to do the RDT but also to do like a dry blood spot so we could test by PCR [polymerase chain reaction] and also a smear for smear microscopy and then we used an alternative RDT that might be able to 00:36:00detect things if there was a mutation that was affecting the detection with a standard RDT. That was another project that we did while I was in Cambodia and unfortunately COVID sort of interrupted before we got the final results of that, but it certainly seemed to support that what we were seeing was real significant declines in malaria in Cambodia--that there were not a lot of people who were being missed by these rapid diagnostic tests.

Q: Can I ask one question about people in the forest--forest-goers--were there small clinics in the forest where they could take these tests or were there just health workers that would roam into the forest with the forest workers?

KUNKEL: It was just the forest workers. They had some training and were equipped 00:37:00with some drugs for malaria, but the main thing was if someone was very sick, they needed to get out of the forest. We're talking about like a really dense, deep, difficult forest environment--not something where--not many people are living there long-term.

Q: Yes, it's a very dense, very low-growth and then above you it's all trees and it's very dark sometimes. Okay you touched on COVID but we're not going to get there yet because I want to talk about one other response which happened before then and that was Ebola. You were actually--you responded to the Ebola outbreak in the DRC [Democratic Republic of the Congo]. Can you explain how you got involved in that and what you did there? Let's also-- anchor us in time, what year are we in here?

KUNKEL: Yes, so this was 2018--so this was the 2018 Équateur Ebola epidemic 00:38:00since it seems like now there's kind of epidemics that are happening every year more than once a year. This was in the Équateur Province of DRC. My position originally with the Pasteur Institute was supposed to have kind of an outbreak aspect to it and be focused on emerging infectious diseases and it ended up being a lot more malaria that I did. When there were occasionally outbreaks then I would have the opportunity to get involved. There was another woman who was working at Pasteur who was formerly with CDC, and she was--

Q: Do you remember her name?

KUNKEL: --oh my gosh, it's Eileen [Farnon]. Eileen was also like a mentor to me 00:39:00there and she was involved in some of Pasteur's outbreak responses and so she proposed that we could go to DRC through GOARN [Global Outbreak Alert Response Network] which is kind of a WHO [World Health Organization] associated response system where different universities can send people to help with responses through WHO, essentially. The idea was that the two of us would go together and she had a lot of experience responding to outbreaks, particularly--or including Ebola. We both put in our applications and I--eventually we heard back, and we got approved and we both applied for visas and for some reason my visa got accepted and hers did not--which I think was related to--we had different French visas and so I think the DRC embassy in France was telling her she should really 00:40:00go through the U.S. one which was complicated because we were in France. Anyways, long story short is that I got approval and she didn't. We talked about it, and I decided that I was interested in going anyways even though I wouldn't really know anybody there--just to have that experience. I flew off to DRC by myself and then met up with people from WHO once I got there. I was told before I went that I would be a surveillance officer, but they didn't tell me anything about what that would mean or where I would be based or anything. Then after I arrived in Kinshasa, I think that day they decided that I was going to go to Mbandaka which is the larger city in the area where the outbreak was and there had been a couple of cases there but not very many--and that I would help mainly 00:41:00with the surveillance and data management. Then I flew to Mbandaka the next day and then met the team there and started working. Particularly, at that time, I think it had already been--I think maybe we had already passed the last case, or we were just nearing the very end of the epidemic. There hadn't been any more cases in Mbandaka--at least that had been diagnosed recently. They had set up this system of alerts where the different health facilities would report if they had anybody who met the case definition of Ebola and then investigators would go and try and determine if they thought this could be Ebola or not. Most of the time I was just based in the WHO compound in Mbandaka working with the data that was coming in every day from the people who were doing these investigations and working with a couple of data mangers who were with either the local health 00:42:00authorities or WHO Africa. That was really interesting, and I got a better sense of how the surveillance was working and just the challenges of keeping everything in a clean database and that sort of thing. It was also a really challenging work environment so that was the first time that I had been in a city where the hotel has no running water, so they give you two buckets of water every morning that you're going to use to bathe and flush the toilet and everything like that. It was challenging to have an understanding of what was safe or not. Could I go walking around by myself and go to the market or that sort of thing or how would I get food? That was a bit challenging to understand. 00:43:00I did end up getting quite sick which is not fun. I got what ended up being diagnosed is malaria--I got pretty sick and ended up having to leave a bit early and fly back to Kinshasa and spend a few days in the hospital there. I wouldn't really recommend that aspect of the experience but otherwise I think in terms of understanding the way that the outbreak responses is happening and the different partners who were involved it was definitely an educational experience to go through that.

Q: You were studying malaria in Cambodia and yet you go to DRC and get malaria. Then you--

KUNKEL: True, so...

Q: --different kind of perspective on what malaria feels like, and you're experiencing it in a country that's not that familiar to you--with people you barely know.

KUNKEL: Yes, it was a challenge to--I mean, I had just started learning French 00:44:00like a year or two before I took this job in France and most of the time I was still working in English. When I went to DRC it was working pretty much entirely in French so that was a challenge since it was still newer to me and then being in the hospital and having to speak French to the nurses and everything was definitely a challenge for my language skills. I guess it also showed that--okay my French is getting there that I'm able to get through this--be through all these sorts of situations.

Q: How did the people respond to you there in the hospital? Was it, okay, we have this person from another country we've got to see? It just--absorb you--is it a special hospital?

KUNKEL: I don't know that many details to be honest. I think it was a hospital 00:45:00that probably saw more foreigners, so nobody seemed very surprised to have me there. One thing that was--that I didn't really understand when I went in is I think in a lot of other countries there's this culture where if you're in the hospital it's like your family who brings you food and they'll care for you while you're in the hospital. Because of that then I didn't realize right away that if you wanted to eat that you had to tell them that--like every meal that you had to order it. I went like a full day without eating before I finally figured out--I had to actually ask somebody if I wanted to order food and do that in a particular way and everything because it's just not what they're expecting for most patients to be doing.

Q: Wow, that's a new skill to learn--and you're sick because malaria is no fun. All right, so then--

KUNKEL: Yes, I--oh, I was just going to say malaria was not fun. I think I had a 00:46:00pretty mild case of it honestly. I would say dengue was worse, so I don't recommend that one.

Q: I'm sorry, you had dengue as well?

KUNKEL: I had dengue in Cambodia.

Q: Is that before you went to DRC or when you're coming back now?

KUNKEL: I don't remember--I think it was after.

Q: Okay huh. Wow.

KUNKEL: Yes, it kind of went through the Institute. I think we were right next to an infectious disease hospital and so our theory was that the mosquitoes were biting people there and then they were flying over and biting people at the institute. I don't know if any Cambodian people got sick, I think most of them were probably immune by that point but there were several expats who went down with it around a similar time.

Q: Dengue--they also call it breakbone fever--so did it feel like your bones were breaking?

KUNKEL: I don't know about that but I felt I mean, I felt very sick. The tough 00:47:00thing about dengue is you can't do anything about it. If you have malaria, as soon as you know that, then you can start treatment and then that acts very quickly. When you have dengue you have basically--you know, you're going to have a fever for a week and so I had a fever of 104° and I would take some Tylenol and it would go down and then I would sleep for a little bit and then I'd start shivering and then just watching the clock for when I could take some Tylenol again and take the Tylenol and then you start sweating and then you can sleep for a little bit. You have this kind of cycle, and they also want to monitor your blood levels, like your platelet levels and things like that, to make sure that you're not going to have a turn for the worse. Then I was taking these Tuk Tuks back and forth to the hospital every day or every second day and I was really feverish and really sick but still had to keep going back and forth to get my blood drawn. That was a challenging one.

Q: You weren't in hospital, you were at home, and then you had to trek back to 00:48:00the hospital for them to take samples?

KUNKEL: Yes, I was not admitted for that one.

Q: Are you living by yourself here or is there someone caring for you at home?

KUNKEL: I had some roommates, and I was actually living at the Pasteur Institute--they had some apartments there. I knew if anything happened, I could get somebody's attention who would be able to help me.

Q: Right, so, you were working in Cambodia and then also we have the beginnings of COVID stirring. How did you first hear about COVID?

KUNKEL: So, I think in 2019 I spent the winter holidays in France and then I flew back to Cambodia in early January of 2020. I think I had started hearing 00:49:00some things about COVID maybe online or some postings, but I remember starting to have some conversations with Patrice and we were both--as more was coming out--we were both watching the news and we were discussing with each other what do you think this is going to be. I remember at one point he said, "Oh, I think this is nothing, it's just going to blow over, it's going to be maybe like the original SARS [severe acute respiratory syndrome] or less than that." Then at another point he was like, "I don't know, this could be like a pandemic flu or something." The whole time I just kept saying, "I don't know, I don't know, it could go either way." I do remember I think it was--maybe it was in late January when the first case was diagnosed in Cambodia and at the time, we were much more concerned about Cambodia than we were about France or the U.S. because we felt like there's a lot of travel back and forth between China and Cambodia-- and 00:50:00Cambodia doesn't have as developed of a health system and so we thought if it's going to go somewhere Cambodia is at risk. I remember I think maybe the day that they had the first case diagnosed in Cambodia I went to the pharmacy, and I bought a packet of masks, and the pharmacy was full of people who were doing that--mainly Cambodians. I just thought to myself you might want to be prepared if something happens, you might want to have some of these on hand. You know, in Cambodia there's I think much more of a culture of masking if you're sick or that sort of thing so the idea of buying some masks didn't seem like such a crazy thing, I think, and wasn't really controversial. Then we had the first case that was in late January and then we didn't have another for a really long time and things kind of calmed down and it seemed like, well maybe it's not that transmissible and maybe it was that food market and that sort of thing. I think 00:51:00that's what probably everywhere in the world was thinking that at the time until it was clear that that wasn't the case.

Q: Are you still traveling back and forth from Paris -- I'm going to ask another question. If you're traveling back and forth from Paris, do you have an apartment in Paris and then you have housing in Cambodia? Is that what's working here--is that the setup?

KUNKEL: Yes, I mean, it sort of varied but basically what I did was in Paris I got kind of a small, cheap studio apartment--like 150 square feet kind of thing--so it would be not too expensive. Then the deal was that Pasteur--like my--I think it was through my fellowship grant--but they would pay for all my flights but then they didn't want to pay for my housing. For a long time, I just lived in apartments that were at the Pasteur Institute and they had mainly 00:52:00shared apartments but after I had gone like twelve or something different roommates, of people coming and going for short times, I felt like I was sort of tired of that and so I did end up getting an apartment just by myself in Phnom Penh with a friend. Then I think for my last six months, my last year, that's what I did--so yes, I had apartments in both. Usually when I would go somewhere I would stay for a few months so I came back to Cambodia in I think early January and then the plan was to stay--I guess to stay until April, I think, was the idea that I would stay until early to mid April. Then the end of my post-doc was supposed to be in May, so this was kind of my last trip to Cambodia. I had--the first week of March--I had a friend from France who was going to come visit me in Cambodia and we were kind of down to the wire, we were debating 00:53:00whether or not he would come and--because we were starting to see that there were more cases in different parts of the world including in France. At the time there was still--maybe there had been two cases diagnosed in Cambodia and that was it and no secondary cases. We ultimately made the decision that he would come, which in retrospect I think that was such a crazy decision and that was not the right choice at all but we didn't really know any better, so we said okay, just come, I don't think it's that dangerous here, and let's have this trip. He came and we spent a week traveling around Cambodia. At the beginning it was fine. I think people were still not that worried about COVID. They were a little bit nervous because he's a Chinese background and so when they--some of the Cambodians would see him they would be a bit nervous but when they saw that 00:54:00we're together and I'm of a Caucasian background then I think they felt more comfortable because they were still thinking of this as being kind of like a Chinese disease.

Q: This is really like April, May 2020?

KUNKEL: This is the first week of March 2020, yes. Towards the end of that week was when cases were really starting to explode like in New York and then in France and then kind of like all over the world. It was like the beginning of March, and we were also starting to see a few cases popping up in Cambodia. I remember the last day of his trip we had been down in some of the islands and went to Sihanoukville and we were in the airport and his flight was before mine so I had to wait for six hours or something in the airport before I'd fly back to Phnom Penh and I just remember spending the whole time on my phone or on my 00:55:00computer and reading about what was happening and figuring out what was going on and I realized wow this is actually--this is a really big thing. I reached out to Patrice, and I reached out to the head of the Institute--Pasteur--in Cambodia and said, "I want to help with the response, and can I?" and they said, "probably, we'll get in touch with some people who we know." This is maybe like a Saturday and then the Sunday I was back in Phnom Penh, and I spent I think the whole day just reading about what was happening and also started to write some things. I was getting calls from friends at church or just different expat friends about do you think I should stay here, do you think I should leave, should we have church tomorrow--like, all of these kinds of questions. There was 00:56:00nobody who was really giving answers and I felt like--well, I'm more qualified than a lot of people to give an assessment of what I think is happening so I wrote up a several page document that was, like, okay here is one epidemiologist's take on what's happening with COVID in Cambodia and just kind of like an FAQ [frequently asked questions]--like, what is COVID and should I be worried and do you think I should go home and all of these kinds of questions. Then I put that on my Facebook page because I figured that I was going to start probably working with the Ministry of Health the next day and I wasn't sure if I'd be allowed to do that anymore. I wanted to get that out while I could. The next day I went into work, and I talked to Patrice a little bit and then went to meet with some of the people who were working on the--Ministry of Health and CDC COVID response. Basically, I just joined up with them and I kept working with them and that was my full-time job from then on when I was in Cambodia. I just 00:57:00kind of dropped the rest of my projects and that's what I did for the next couple months.

Q: Could you give me an example of what that day-to-day looked like at that time?

KUNKEL: Yes, the team that I was working on at least was really focused on contact tracing. When I got there, it was still so early that they had a line list that was written--it was on a whiteboard. It was like the name of every person who'd been diagnosed, and they were on the whiteboard of where were they and how many contacts did, they have and how many of those were followed up and this sort of thing. Really quickly the numbers were starting to blow up and it wasn't--we actually were not seeing a whole lot of secondary transmission in Cambodia, but we were seeing imported cases who were coming from all kinds of different events. There was one group that was a French tour group and basically the entire bus of people ended up getting infected. There was another one that 00:58:00was a group of people who had been to religious events that--I think was in Indonesia or something--they came back and then it turns out more than half of them were infected and that sort of thing. The idea was trying to identify these people who were infected and then Cambodia was isolating everybody who had a COVID infection so they were all going into a hospital or health center or somewhere and they were staying until they had at least two negative PCR tests and those criteria were kind of changing over time about when exactly we would let them out of the hospital. Then all of their contacts were supposed to be followed up every day by phone to make sure that they were healthy and then if they had any symptoms then they would get tested. I think they got tested maybe at the end of quarantine no matter what or something like that. That was really the focus on it and then--so I did some technical advising on different aspects 00:59:00of that but the main thing that I did was work on creating a database for the contact tracing. I worked with somebody who was with the WHO in Cambodia and then obviously the Ministry of Health and people who were there. There was also a guy from CDC who I had met previously who was really involved in the response who was kind of overseeing us. That was our big project for the couple of weeks that I was there--I mean, the couple of months that I was there--was setting up that system so that we could track what was happening with the contact tracing. It was interesting in Cambodia--it was not what I would have expected in a million years, you know? That we had so much COVID exploding in New York and in Paris and in these types of cities and meanwhile Cambodia was relatively 01:00:00protected. I think we still don't know exactly why that is but they had, I think--there were these waves of imported cases that came and then occasionally there was some secondary transmission to one of their family members so that sort of thing. We were just not at the time seeing any kind of big explosion of cases. Actually, by the time that I ended up leaving Cambodia in the middle of May, we'd been I think more than two weeks with no new cases diagnosed which is just not at all what I would have expected, I think, back in January looking at this new disease in China and thinking about the risks that Cambodia was at compared to places like the U.S. or France.

Q: There's a couple questions here I have about that. You were saying there are a lot of--they were isolating--so was there a lot of hospital space or were they isolating at home? Did the hospitals have a lot of PPE [personal protective 01:01:00equipment] just like other places?

KUNKEL: Yes, mostly isolating in hospitals. I didn't go to any of these in person so I can't say too much about what it was like. I think it was often not a very pleasant place to be for a week or so. In some cases, they were able to do isolating in a hotel or that sort of thing for some of the foreigners where there was a big group of foreigners and it would have been too complicated to put them in hospitals, but most people were being isolated in the hospital at that time.

Q: Do you remember the name of the guy who was from CDC?

KUNKEL: His first name is Vanra [Ieng] and I'd have to look up his last name.

Q: Okay. Here's another question I have--

KUNKEL: Oh sorry, that was the WHO guy. You meant the CDC guy.

Q: Yes.

KUNKEL: Yes, Michael Kinzer.

Q: Okay. Now something that you were talking about or that you might want to 01:02:00touch on were the different attitudes towards risk and illness and you experienced those with malaria and dengue and there's a parasitic disease there that you haven't explained--and the difference between those older types of diseases and now we have this new emerging infectious disease. What is the difference in the attitudes in--well, I guess, we'd have to say Cambodia--during this period of time?

KUNKEL: Yes, I mean, I think that topic came up that--you know, I was thinking even just about myself. When I was doing my post-doc and I was in Cambodia, and I was in DRC I was kind of aware that I was putting myself at risk of certain diseases. I ended up getting malaria and I ended up getting dengue and that was not fun, but it wasn't entirely a surprise. I think that I was aware that that 01:03:00was a risk that I was taking in being there.

Q: Those were known diseases.

KUNKEL: Yes. It's just interesting to me--so now it's two years into the pandemic and I've been working at home for the last year and a half, and I've been very much limiting my activities and wearing a mask whenever I'm going everywhere. The tolerance for risk is just I think really different. I think a lot of that is that it's not--I mean, a lot of it is what you're saying that it's new and so there's that fear on that. I think a lot of it is that I think there's more acknowledgment with COVID that if you get infected then you're directly infectious to other people whereas with something like malaria it's a 01:04:00little bit harder to see that cycle because, you know, there's a mosquito in the middle. It's not necessarily that you're--you're not necessarily going to have the feeling that you're infecting somebody who's around you even if you eventually traced it back through the mosquito and were able to say that's the case. There's I think kind of more of that feeling of responsibility to not infect other people as well. Yes, and then, I mean, I think I'm obviously in a privileged position where I could choose to travel to Cambodia or not to, or I could choose to travel to DRC or not to, and then if you're someone who actually lives in that country these are risks that are--you can't avoid, they're always there. You don't have the choice about whether you're going to face that or not. I think if you're already experiencing probably some of these--I'll give you the 01:05:00example of like when I was in DRC. When we were looking at the alert data from Ebola, there's just so many infectious diseases that are going on in the city that I was in, there was so many people who were having symptoms that could have been consistent with Ebola but most likely they were probably malaria, or they were parasitic disease, or they were any kind of number of other things. I think there's already such a high burden of infectious diseases that maybe in that environment the idea of one more doesn't seem like quite as much. I don't know, I haven't been in DRC since COVID started. Yes, and I think if they're--you feel like you have more control if you're trying to prevent it coming in versus if it's already there. Cambodia for many months after the pandemic started was in a 01:06:00really good place in the sense that there was not really any local transmission going on. It was really just a question of could they prevent it from being imported. Unfortunately, they couldn't keep that going forever but I think a lot of those Southeast Asian countries were in a similar place. Then once you already have--the cat's out of the bag and you already have malaria in your country or you already have dengue in your country it's a lot harder to try and control it after the fact, I guess.

Q: Yes, prevention. Your time in Cambodia ends and you go back to Paris, and this is in the middle of a pandemic because pandemic was declared a pandemic by WHO on March 11, 2020. Did COVID--did it affect your travel? Did you have to 01:07:00quarantine when you returned to Paris?

KUNKEL: Yes, it absolutely affected my travel. I think I had told you I was planning to leave in the middle of April and then basically it was around this first week of March that everything was exploding. There was a decision point at that time, which is do I go back to France, or do I go back to the U.S., or do I stay in Cambodia. I had gotten tied in with this group that was working on contact tracing, and I felt like that was really important and valuable work. It was kind of an all-hands-on deck situation in Cambodia. I think a lot of the time if you have an epidemic--so if we're talking about Ebola, for example--the model with Ebola would be that there's--okay if there's an epidemic of Ebola somewhere then you're going to have all of these outsiders flying in to help and 01:08:00that might mean CDC. When I was in DRC it was a lot of people--a lot of Africans, and particularly from West Africa--who had experience with Ebola in West Africa and so they had that experience, and they were able to bring that to DRC. Wherever they're coming from basically you're getting people who have this experience who are coming in to help. When it came to COVID in Cambodia that was not the case because everybody was dealing with COVID where they were and so we couldn't rely on anybody coming to help. I think it was basically a question of who's here who can do this. Certainly, it was the Cambodians, the Ministry of Health. People who'd been trained through the field epidemiology training programs, for example. Then there were also some international people like me. I 01:09:00felt like I was comfortable working in Cambodia, I had been living there on and off for three years, and I really felt like that was where I should be. I decided that was what I wanted to do and then I had to try and protect myself though because my contract was ending in May and what was happening by the middle of March is that so many flights were getting canceled and all of the flights that you would take out of Cambodia--those routes were basically stopping. You couldn't fly through Vietnam anymore, you couldn't fly through Thailand anymore, you couldn't fly through China anymore. All of the flights that you would fly out of Cambodia to get anywhere were not available. I felt like I kind of had to plan for--what if I get stuck, what if I can't leave here--and I said OKAY well my contract ends in May--well what if I can't leave in May, what am I going to do about health insurance? I was talking with the 01:10:00director of the Pasteur Institute there and trying--saying are there things that we can do, can we put some precautions in place, can you guarantee me that you can somehow extend my contract if I'm stuck here past May--and that sort of thing. I think, yes, to her credit and to the credit of a lot of people around there, I think they really tried to make that happen and made it feel like--I felt like, okay I'm comfortable staying in Cambodia and that if I can't get home that that will be alright. I kind of had those plans in place but I was hoping that I didn't have to use them. Then around the middle to the end of April I realized that cases were going down and our database was basically set up. My French visa ended in the middle of May so if I wanted to go back to France where 01:11:00I still had an apartment I needed to go soon. I was able to find how to do it--basically--actually the French embassy had posted--the French embassy in Cambodia had posted--if you want to get to France from Cambodia here's what you do and here are the flights that you take. It was kind of complicated, it was like you had to fly from Cambodia to Seoul [South Korea] and then you have an eighteen-hour layover and then you fly to Doha [Qatar] and then you fly from there to Paris. Complicated, but there was a way to do it. Then once I saw there was a way to do it and it seemed like it was a good time to leave then I did that. The other thing that I actually had to work around was--so I had applied to EIS again in 2019 to start in 2020 and so I'd been accepted in October of 2019 and so I knew that was what I was going to do after my post-doc--but I 01:12:00hadn't matched or anything yet. Normally there would be the EIS conference that would be in early May and so I think that's part of why I was going to leave Cambodia in the middle of April was so then I could make sure I could get to EIS conference in early May. Well, now that was canceled because of COVID but I still needed to interview and match and everything. I ended up having to also plan my flights around that schedule--around the EIS interviews that ended up being held virtually. That was kind of a crazy time that I was trying to learn about these positions and I was trying to do these interviews and at the same time I was working seven days a week on the COVID response and just--you know, very stressed about that and stressed about moving and on top of that having these EIS interviews to think about that were--there was an eleven hour time difference so I had to calculate when I was going to do the interviews so it 01:13:00wouldn't be in the middle of the night and that sort of thing. That was also going on at the same time.

Q: Okay, so thank you for bringing up EIS, we'll get to that in a minute. I wanted to ask you as working for the Pasteur Institute as a contract worker and you're living mainly in both places--France and Cambodia--did you feel more connected to Cambodians than you think others would have felt just coming in? Because you were talking about when COVID response--other people come into the country all of a sudden and you have these people coming in that haven't been there before, but you've been there many times and you're more connected. Did you feel a lot more connected during the response?

KUNKEL: Probably to some extent. I think I was kind of used to I guess culturally working with people in Cambodia and so that was familiar to me and 01:14:00also I think just the idea of living in Cambodia during a pandemic--that was a lot less intimidating to me than for example when I went to DRC but, you know, that was quite challenging because it was somewhere that I had never been before and I wasn't as familiar with the security situation and how do I get around. In Cambodia I was very comfortable, and I knew this is how I can get food, and this is where I need to go to the hospital if something happens, and I had a support system. I think that all made it easier for me. Then definitely I felt--I mean, I think anywhere that you go you care about the people, but I think I probably identified more with Cambodians than maybe somewhere else if I hadn't been living there and working there already that it felt very important to me that Cambodia be protected from this pandemic because it was--in some ways it felt 01:15:00like my country, too. That it was somewhere that had welcomed me there for the last several years and so that seemed important.

Q: Were you able to help others that were coming in that were not as familiar with Cambodia?

KUNKEL: A bit. Do you mean like people who are coming for short-term?

Q: Yes.

KUNKEL: Yes, I mean, like for example I had some master's students who came to work with me one summer. I think I was able to direct them different places and help them kind of get used to what it's like to live in Cambodia. To be honest it's not that difficult to live in Cambodia, at least it wasn't while I was there. As an expat I think they have enough tourism and that sort of thing that it's really pretty easy to get around and to feel comfortable there.

Q: Okay, so let's turn and pivot to EIS. You were explaining how you--the 01:16:00matching period. Once you're accepted then you have to go through--not have to go through but you go through a process of matching and that usually happens during the EIS conference which is really--end of April, early May. That's where you interview with people who are looking for an EIS officer to join them during their two-year stint which is what EIS is--its' a two-year program. How many interviews did you do and--well, thankfully you were able to do these--because you have to do them usually in person--thankfully because of the pandemic and--not thankfully because of the pandemic you had to do them remotely--everybody was doing them remotely. It was kind of easier--not easier, but helpful that you could do it from another part of the world. Other people had to do phone calls in the past. You were doing them probably as Zoom calls since you were able to see the person you were talking to. How many interviews 01:17:00did you do?

KUNKEL: I think I did eleven interviews. I did a lot of interviews because--the suggestion had been--there's kind of like this pre-interview period where they encourage you to meet with the supervisors and the EIS officers who are currently there and that sort of thing in advance of doing an interview and then you do the actual interview and basically, I felt like that was too much. I sent some emails and I think I did end up eventually talking one-on-one with the EIS officers for most positions, but I just planned that I would do a lot of interviews and do that instead of meeting with a lot of people ahead of time.

Q: What interested you in matching to the Poxvirus, Rabies Branch?

KUNKEL: I think a few things. One thing is I knew a little bit about rabies--actually Pasteur has kind of a long rabies history and so that's kind of 01:18:00one of their mandates is they work on rabies because Louis Pasteur is the one who invented the rabies vaccine. In Cambodia, for example, the Pasteur Institute is--or at least was at the time--the main place that people would go to get rabies vaccinations. I kind of had some awareness of the disease from that standpoint. There had actually been this incident while I was there--maybe it was in 2018, I'm not sure where--there had been a child who had been bitten by a cat and then--a Cambodian child--and ended up developing rabies and dying. Her family put--they posted a lot about this on social media, and it basically went viral in Cambodia. People were seeing this and realizing the dangers of rabies and it--as a result at the Pasteur institution we were just mobbed by people for 01:19:00several days, a week or something--there would be thousands of people just standing in the parking lot because they were worried about a dog bite that they'd had maybe a week ago or maybe ten years ago or whatever. That was kind of an interesting thing to see, just the panic and terror that rabies can generate in people when they learn about it. I had some awareness of rabies and then one thing I liked about that position was that it had both kind of a domestic and international aspect to it. They worked both on rabies internationally where there's still tens of thousands of people who die from dog mediated rabies every year but then also, they work in the U.S. where we've eliminated the canine 01:20:00rabies virus variant but there's still rabies present in wildlife and so people are still exposed when they're bitten by a raccoon or when they're bitten by a bat or that sort of thing. I knew with COVID that, at least at the beginning, it might not be possible to travel internationally and so I thought that being in a position that had a domestic focus would also be interesting. I also figured probably long-term I would want to work internationally and so getting to see how some of the domestic public health works during EIS would also be a good opportunity. Then I like infectious diseases, that's what I've focused on throughout my whole career and so that was another appeal, of course, with rabies.

Q: Okay. How did COVID--the COVID response--impact the work of this branch?

KUNKEL: One of the main things that I've seen is that it's really affected travel. Normally from what I've heard the branch does a lot of international travel. A lot of what they do is capacity building and helping countries to build their surveillance capacity and also dog vaccination capacity for rabies control. We haven't been able to travel at all since I've joined. I haven't done any international deployments and we're still trying to work with some countries, but it's been mainly virtual, so I've been working particularly with Zambia, for example, and they're trying to set up integrated bite case management system and do some pilot dog vaccinations. We've just been doing it through Zoom calls back and forth which, to be honest, is really challenging. I 01:22:00think it's really hard when you're not there in person to really understand even who are the main decision makers and then where exactly--what exactly is the status of the project and what needs to be done and what can you help with. That's one thing that was definitely affected. A lot of people were deployed. When I first started EIS, my supervisor was deployed with the--or I think detailed with the One Health working group that was looking at SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] infections in animals. He continued to be there through the first six or nine months of my time with EIS. There certainly were a lot of other people who were deployed as well. Those are some of the main ways we saw.

Q: The One Health office--that was your first deployment as an EIS officer?

KUNKEL: That's correct. The first month of EIS is training and so that was July of 2020 and then when I started for real in August my supervisor, Ryan Wallace, was working with the One Health working group and he invited me to join them to do my surveillance evaluation. Every EIS officer their first project is typically evaluating a surveillance system and so in this case I got to work on the surveillance that we were doing in the U.S. of animals with SARS-CoV-2 infections which was just a really interesting experience. I had never before joining CDC--I had never really worked with anything animal related before. I had only been working with people really. To start thinking about all of the 01:24:00challenges involved in animal surveillance and who were the different players, for example. What is the role of CDC, and what's the role of USDA [United States Department of Agriculture], and how are those defined, and how do those change over time depending on who has time, and who has money, and that sort of thing? That was a really interesting thing to see and understand a little bit more about how that works.

Q: The difference of human versus animal surveillance.

KUNKEL: Yes, but then, I mean, even within animals--CDC is responsible for animal rabies surveillance and that--even though it's a disease in animals that's something that falls under CDC's mandate. We at the rabies branch--we get data on every animal that tested for rabies in the U.S. every year and some 01:25:00detail on species, and what county they're in, and were they positive or negative, and that sort of thing. There is some animal data that goes through CDC. Then CDC obviously has a big role in zoonotic diseases, diseases that affect companion animals, for example. Whereas USDA is really the main one who's in charge of most diseases that are affecting livestock. Sometimes the boundaries between these are not entirely clear. When I came to animal SARS-CoV-2 infections, both CDC and USDA were involved. Most of the laboratory testing was happening at USDA but I think that's not necessarily the way it would always be but it was that CDC was so overwhelmed with human testing that it kind of ended up making more sense for the animal testing to go with USDA. Then CDC was still involved in developing forms for animals who did end up 01:26:00getting diagnosed with the SARS-CoV-2 infections, and case report forms about the animal, and then also about the humans around them and trying to understand did the humans affect the animal or is it possible that the animal infected any humans, and that sort of thing. Both were really playing a key role there.

Q: You touched on this a little bit but how do you think the response affected your EIS training?

KUNKEL: I mean, the main thing is the virtual. Everything has been virtual, basically, since I started. I started in July of 2020, and it is now April of 2022 and I've officially been back in the office two days and that's it.

Q: Welcome back!

KUNKEL: Thank you. I think I had kind of heard before I joined CDC that EIS is known as like the CDC fraternity. It's like a way of really meeting people and getting to know people and having that kind of network I think that is something that has been kind of missing from our experience. That when we first started it was still summer of 2020 and people were very cautious, so we did some meetups in small groups outdoors and that was about it. Our whole class never got together. Nobody was vaccinated at that time point so we were still being very cautious. Then the other one of course is of course work on COVID. I would say about half of my EIS experience has actually been with the Poxvirus, and Rabies Branch and about half of my work has been on different COVID.

Q: (pause) I lost you there for a minute. It is Zoom. Half of you--you're saying half of your deployments were--half of your work in EIS was on COVID and the other half was pox, rabies?

KUNKEL: Yes.

Q: All right. The class really never got together ever. Do you ever think you're going to have like post--after this is--because you're all graduating--there's air quotes around that--in May--next month? You're--

KUNKEL: June.

Q: --June, okay, good. After that do you guys think you're going to get together now that we are pretty much all vaccinated and get to know each other before you all scatter to the winds?

KUNKEL: We'll see. Next week is actually the 2022 EIS conference and the 01:30:00conference is virtual again officially, but I think almost all EIS officers are actually coming into Atlanta so I'm hoping that we'll be able to spend more time together and get to know each other a little bit better. The field officers came in also in this past fall for a few days--I think for the medical checks and that sort of thing--and so that was another opportunity we got to meet people and do a little bit more kind of team building, networking, and that sort of thing. There's been some of those but probably not as much as normal.

Q: Did it make you feel more isolated as an EIS officer? I mean, just working, teleworking makes you feel isolated, but expect. Did your mindset change a lot when you were suddenly in EIS, and you entered with one expectation and then 01:31:00while you're in it you have a different experience?

KUNKEL: I don't know so much about that. I mean, I don't know if I would have a much more difficult experience as an EIS officer than as any other person working at CDC. I definitely--you know, I find working from home to be really challenging. That's not a surprise to me, I think I kind of was aware of that from my PhD that I really get a lot of enjoyment from my work from being around people and from my colleagues and that sort of thing. Missing that it definitely takes a lot of the enjoyment out of work, I think. I mean, there's definitely this feeling that--I guess it's a little bit ironic that it's--well I moved here to the U.S. from France so that I could do EIS and I've basically sat in an 01:32:00apartment by myself for most of the last two years. That's just a little bit like--that's just a little bit funny, I guess, to be like okay I moved all the way here and for what, basically. I think at least in my case that's had an influence on whether I wanted to stay at CDC or not and I've ultimately decided that I'm not going to be staying at CDC for now. Ultimately, I've decided that I'm actually going to move back to Europe and try something else, I think. I think I might have a very different feeling if it had been two years of actually being in person working at CDC. Just I think the pandemic has been really discouraging for public health workers in general and people at CDC and feeling like--does our work really matter, and can we actually see the result of 01:33:00the efforts we're putting in, and do other people see the result of that? It's been kind of discouraging, I guess.

Q: Thank you for that. Well, let's move on to your second actual deployment. You were detailed to the San Carlos Apache Tribal Nation. Let's have you talk about that.

KUNKEL: Yes, I was aware of some people doing deployments with different tribal nations starting from my first few months in EIS and I thought that sounded really interesting and like something that I would like to do. The way that I ended up getting involved was that I first ended up doing a virtual EOC [Emergency Operations Center] deployment. There were a few people [Rachel Burke] 01:34:00who had developed this tool that was written in R--in R Shiny--that could upload data from a service unit with the Indian Health Service or at a--with a tribal reservation and then run some analysis on that and spit out a Word document that had the epidemic curve. It had some key variables like what was the percent positivity of testing in the last two weeks, and how many cases were detected in the last two weeks, and that sort of thing. They wanted to keep developing that tool and they were looking for somebody to work with them on it and I have a lot of coding experience, and data analysis experience, and that sort of thing. I volunteered to do that and I spent a month working on this tool and then towards the end of it they came to me and said we're thinking about using this as part 01:35:00of an actual in-person deployment--field deployment--that we're going to do at the San Carlos Apache [Reservation]--so you're the first person who we thought of because you've been working on this tool and you know how to use it really well and so would you like to go. I said, basically, of course. I flew out to Arizona with one other EIS officer and our team lead, and we drove from Phoenix to the San Carlos Apache Reservation so we could meet with the tribal public health leadership there and talk to them about what their goals were for the deployment. There were a lot of things that they were doing there--I think in some ways it was like the closest to the work in Cambodia because there were 01:36:00some similarities in their approaches to the way they were dealing with COVID and then also I think just in the sense that it was sort of like a more nimble response because it was a smaller area and group of people. They'd been doing some different things--so they, similar to Cambodia--they were isolating every person who had been diagnosed with COVID, they had converted their casino hotel into basically an isolation facility. That was a big part of their response that they were doing. They were trying to do a lot of testing-- they had done a lot of community mitigation strategies. They were trying to tell people that there's only certain days that you're allowed to travel, the other days you have to stay at home, and then there can only be gatherings up to such and such size, and this kind of thing. You know, trying to put a lot of measures in place to keep 01:37:00the disease from spreading there. I mean, what a lot of tribal nations saw and what they saw there, too--which is quite sad--is that there were still big epidemics of COVID on some of these reservations and often a high mortality rate as well. They, I think, were really doing everything they could to prevent that from happening as much as possible. Then another thing that they were doing there was they were really, I think, ahead of the game with the vaccine. They had started planning well in advance for when they would start getting the vaccines which they got through IHS [Indian Health Service] so that, you know--I think the day after they received the first vaccines they were already putting shots in arms and they started--I think like everywhere else, they started with their front-line healthcare workers and then moved on to the people who are 01:38:00elderly or had different health conditions. I ended up doing some analyses with them and compared to the vaccination rates of the State of Arizona as a whole they were way ahead. Just the number of--the proportion of their population that they were vaccinating every day. They were doing a lot to try and get that to work so they were doing drive-in vaccine clinics, they were doing pop-up clinics at different events and locations, and they were calling up every person who they knew who was a member of the tribe who had been to the hospital within the last three years who was in some of these different risk categories--they called them up and tried to talk to them and encourage them to get the vaccine and told them how to do it. I was really impressed by their vaccination campaign and that 01:39:00was one of the things that I worked with them on was not only using the reporting tool to report what was happening with their cases but also to put out some reports that were showing their vaccination rates and how many people they were vaccinating every week, and how many of those are in different risk groups, and that sort of thing--so that the tribal leadership could stay on top of what was happening in the tribe.

(phone ringing)

KUNKEL: All right, sorry about that.

Q: Okay, so the tribal leadership was able to stay on top of that?

KUNKEL: Yes.

Q: Okay. Why was there such a high mortality rate in the very beginning?

KUNKEL: I mean, I think a lot of it is related to different preexisting health conditions that people have. In a lot of these tribal reservations there's a lot 01:40:00of historical reasons that people don't have I think as many options for their health, and their mobility, and that sort of thing. Living on a reservation is--people who are part of the majority population would--so there's kind of this just already existing disparities in terms of health, and access to services, and that sort of thing that are then just really exacerbated by the pandemic.

Q: Yes, the pandemic has really shed a light on health disparities in a high--so their vaccination rate was pretty high?

KUNKEL: Yes.

Q: Was there any vaccination resistance at all or--

KUNKEL: Yes, I mean, there was--I think probably every community in the U.S. has 01:41:00dealt with some vaccination resistance. They were trying to come up with different ways to fight against this. Making sure that they had tribal spokespeople who were speaking for the benefits of the vaccine and who were able to do that in the Apache language and speak to the elders. They would at every tribal council meeting they would talk about the vaccine, and they would have people from the hospital who were presenting and from the public health department. They were, I think--you know, sometimes religious communities that were discouraging vaccination like we've seen in many communities. I mean, certainly some that are also encouraging it--I won't want to give the sense that that's the case with all religious communities. I think there were challenges 01:42:00on--but many of the same challenges we would see anywhere else.

Q: Is there anything else you want to talk about San Carlos deployment?

KUNKEL: I don't think so.

Q: All right. You're also assigned to the Emergency Intake Site for unaccompanied immigrant children in--we are in 2021 now.

KUNKEL: Yes.

Q: This happened in 2021, so you want to describe that you--your role there.

KUNKEL: Yes, so this was around spring of 2021. There was a large influx of children who were crossing the southern border into the U.S. who were not 01:43:00accompanied by any adult. The process that happens when these children are picked up is first they go to a Customs and Border Control facility and that's supposed to be a really short amount of time--like a few days. Then they're moved to these Emergency Intake Sites--at least during the emergency response that's what was happening. A lot of these facilities--like the one that I went to, it had just been stood up I think less than a month, maybe, prior to me getting there. They were taking in hundreds of children and the idea was that basically they're supposed to have a safe place to stay while the case workers are working on matching them up with an adult who is going to basically sponsor them or care for them within the U.S. while their immigration details are 01:44:00getting worked out and everything. Ideally, they should be spending just a short amount of time in these intake sites and then they get moved on to wherever they're going to stay with the adult that they get--that's located for them to stay with. In this case there was such an influx that some were staying for many weeks, or more than a month, or that sort of thing. Then the challenge then, of course, this is happening on top of the pandemic. You have all of these kids who are coming in and they're then getting put into these living facilities where they're all very close together. It's likely that some of them have been exposed to COVID on their trip over here or during their stay at the CBP [Customs and Border Protection] facility or something like that. You have this big challenge 01:45:00of basically infection control and what do you do if children start getting COVID--and not only COVID but there's other infectious diseases that can go through these sites as well. Things like strep or even things like measles if people aren't vaccinated. There's a lot of different potential infectious diseases. The sites were run under the Office of Refugee Resettlement but then CDC was there basically invited to advise on the infectious disease protocols and control of these different sites. That's what I was doing and so some of the things they were putting in place were--they were doing COVID screening of all of the children. I think every three days the kids were getting COVID rapid tests. Then as soon as somebody would be diagnosed with COVID then they'd be put in an isolation area and then the children around them would be quarantined. 01:46:00Then in some cases that's affecting people's timelines on leaving. Maybe a kid has--their sponsor has been identified and they're ready to go and they could potentially be on a plane two days from now but now they've just got diagnosed with COVID and so now they need to stay there for ten days. Then everything needs to change for them. It's tough because you are kind of being like the bad guy in that sense it feels like. You're the one who's maybe preventing some of these reunifications from happening. Yet it's also important because you don't want a child who has COVID to then be getting on an airplane and potentially infecting all of the people around them. Even their family members who they end up meeting up with afterwards and that sort of thing. I mean, I think it was 01:47:00kind of challenging in that sense and it was just challenging--so I had mentioned this site had just been set up. Everything was still really getting sorted so they--a lot of the data flow and that sort of thing had not been set up yet.

(phone ringing)

KUNKEL: I'm really sorry I probably need to take this call. Is that okay?

Q: That's fine, we'll pause.

KUNKEL: Okay thanks (pause) -- okay I think that's probably fine-- I'll just keep a little bit of an eye on this in case I get any more traffic.

Q: Okay so we were talking about the Emergency Intake Site for unaccompanied immigrant children. There was a lot of children in tight places, a lot of infectious diseases. Was there a triage of control of those? Did they provide vaccinations for these children before they sent them on?

KUNKEL: Yes, normally there's a couple key vaccines that the kids are supposed to get I think within their first couple days of arriving. Particularly the measles, mumps, rubella vaccine. When I first arrived, those procedures were 01:48:00still not completely set up yet. Some of the kids were staying there for longer periods of time--like maybe even weeks or more--without getting the vaccines yet. That ended up getting fixed pretty shortly after I had started at that site. They also were trying to do the screening I think at the CBP facility so that they would know in advance children who currently had COVID and then you would kind of be aware of that and it would go straight into isolation. They were also supposed to--I think they had kind of like a health screen when they arrived as well. Of course, you can be infected with a disease but not be sick yet by the time you arrive so you can be within the incubation period. That happened as well.

Q: Was this is a hard deployment for you mentally--and I'm thinking on the topics of social justice?

KUNKEL: Yes. I would say it was difficult. I think that I felt like for the most part the people who were there--people were doing the best that they could. I think that was sort of what I held on to as much as I could (pause) I don't know, some things that I've kind of heard about the sites since leaving makes me concerned about how much that was actually the case. I think some things were maybe being buried to kind of avoid having an issue rather than 01:50:00bringing everything up and dealing with it immediately in a way that would have been better for the kids and better for everyone involved. I think it's just so hard to see when you're only--to tell when you're only there for a week or two weeks what the real dynamics are and what's really happening there. It was also challenging--so this was in a small town in Texas and--kind of like, Southern Texas--there were some kind of challenging dynamics with the population in the town. I had some colleagues there who were Black, for example, and it seemed like they were getting unreasonably stopped by the police, unreasonably harassed 01:51:00by the police in some situations, not necessarily feeling like we were very welcome. There was one point where there were concerns that there would be a protest at this site and so there were a lot of discussions around what kind of security there could be and how we could deal with that. Fortunately, in the end, there ended up--the protest didn't happen and that's a good thing, but it was a concern for a little while.

Q: Can you describe an example of what you saw with some of your colleagues? Or heard?

KUNKEL: For example, I had a colleague who had an incident where she was kind of being followed by a car, she didn't know who it was or if it was an official 01:52:00police car or not. In the end, ended up getting pulled over and got treated pretty aggressively by the police officers and they tried to pull her out of the car, and she was still wearing her seat belt and they were accusing her of doing all sorts of things that that she'd committed a felony and kind of this really scary situation. Then at the end of the whole thing they just gave her a stop sign citation and let her go. Hold on just a second, sorry.

(phone ringing--- pause)

Q: We were talking about your colleague.

KUNKEL: Yes. Yes, so she had this really scary situation where she'd been pulled over and I think was really kind of frightened for her life in this situation. 01:53:00Thinking about the number of unarmed Black people who've been shot by the police over the last several years--that was very present in her mind going through this experience. In the end just kind of stop sign citation and that was it and got to go but was I think really shaken by the whole experience. That then ended up being something that we had to raise with the people at the site and then also with talking to CDC about sending future deployers and what are the safety precautions that we should be taking for them and making sure that that doesn't happen again and that kind of thing.

Q: This is in your own home country, not DRC.

KUNKEL: Yes, it was definitely--it was really like a shocking experience, I 01:54:00think, to feel like we were having these questions about is it safe for people to be driving at night and that kind of thing that I wouldn't expect to be having for a domestic deployment necessarily.

Q: Was this around the time of the election?

KUNKEL: No, it wasn't. This was six months later.

Q: Then let's move on and you're back with pox, rabies and--

KUNKEL: Yes, I mean, so I basically--I was on and off with the pox, rabies the whole time. A lot of the time when I was doing some of these deployments, particularly the remote deployments, I'd be also working on some of the poxvirus, and rabies. I had some cool experiences. I got to go to Alaska in my 01:55:00first couple of months here. There had been a new case of this disease called Alaskapox that has only been seen in a handful of humans around the Fairbanks area and we wanted to understand where it came from and went with a team up to Alaska to sample small mammals and to try and look for evidence for the virus in them. That was one example. I worked on a modeling project, actually, that was looking at working with rabies data from Haiti and it--in Haiti--so dog vaccination is the most effective way of preventing human rabies. You prevent rabies in dogs and then as a result you prevent rabies in humans. They had been kind of moving towards more consistent vaccination programs but then in 2019, I 01:56:00think, didn't have--they ran out of funds before they were able to vaccinate the whole country. Then in 2020 the pandemic happened and so they weren't able to vaccinate any dogs at all. They were starting to see an uptick in rabies cases in dogs in--by the fall of 2020. We did an analysis that was to predict what was happening currently and then what would happen over the next several years if there was not an improvement in--another rabies vaccination in dogs. We're predicting basically a big rabies epidemic and that potentially hundreds of humans could die from rabies. That ended up sparking--well, the combination of that and then also there were shortages of human post-exposure prophylaxis in 01:57:00the country and the combination of those led to us talking with some of the travelers health groups at CDC and we ended up putting out a travel health alert for people who were traveling to Haiti to say that the risk of rabies is elevated and that you might not be able to access post-exposure prophylaxis and so you should consider pre-exposure prophylaxis and then if you're exposed by a dog then you should consult with your doctor and you might need to return to the U.S. for treatment and that sort of thing. Ended up also putting out fliers at airports for people who were flying from Miami to Port-au-Prince also to tell them about the rabies situation in Haiti and how to protect themselves from rabies. That was some really interesting work that I was doing there.

Q: How do dogs get rabies, by the way? Where do they encounter it with other wildlife?

KUNKEL: In countries that have canine rabies they get it from other dogs. If they're fighting or--it comes mainly through a bite. They'll be bitten by a dog with rabies and then a few months later they can develop rabies and then they might bite another dog and that's how it persists.

Q: Okay. One of your other non-rabies things was the multi-state outbreak of melioidosis.

KUNKEL: Melioidosis.

Q: Thank you.

KUNKEL: Yes, so that was another thing that I got involved in through--indirectly through the rabies work. There was a child in Texas who 01:59:00developed encephalitis and had a lot of--pretty consistent with what we would expect from rabies and also had a pretty concerning raccoon exposure. We thought this was a really high probability rabies case. The state contacted us. We were planning on doing rabies testing. We don't normally accept samples over the weekend so I think we were waiting until Monday for them to send us the samples and then the day that they were going to send them I got a call from one of my colleagues in Texas saying, "Amber this kid has just been diagnosed with melioidosis and her sample just tested positive for burkholderia pseudomallei," and I said, "Can you spell that please." I didn't know anything about it but I contacted my supervisor and then the lab team to ask if they still 02:00:00wanted the samples and one of the people on the lab team recognized, like, hey, wait a minute, this is a select agent, this is on the select agent list and we're not even allowed to accept these samples anymore in our lab--so it's kind of a big deal in that sense. We started talking back and forth with--this is being managed by Bacterial Special Pathogens [Branch] at CDC--is the branch that deals with melioidosis. I mean, people are not very familiar with melioidosis, and I think the physicians were a little bit unsure if that was really causing all of her symptoms or is it possible, she had rabies and melioidosis or what could be going on. Maybe a week or so later I was on a call with the people from Texas and also from Bacterial Special Pathogens [Branch] and they explained to us that the child's samples actually they had done whole genome sequencing and they matched basically perfectly with a patient who they'd seen a couple months earlier in 02:01:00Kansas and another patient around the same time in Minnesota--they all had the same strain. These patients didn't know each other, they had as far as we knew nothing in common. They said, you know, we think it must be some kind of contaminated product that they all had contact with. This is really alarming, and they wanted to launch an epi-aid [epidemiological assistance] and look into it. Just with the timing there--so it was around the end of June. They didn't have an EIS officer available with their branch to respond and since I had already been involved, they invited me if I would like to get involved so I said yes. A few days later I flew to Minnesota and then I met up with the EIS officer there and people from the state health department to talk to the family members of the patient in Minnesota. Unfortunately, it was difficult to learn very much 02:02:00from this patient since he actually moved--his family had moved him out of his apartment while he was in the hospital. They didn't have many products left over at all that he would have been using. We weren't able to get a lot of information there. Then I went from there on to Texas where I met with the family members of this child and collected samples from some of the different households where she had spent time and some of the products that they were using and some of their environmental samples as well. We looked at all of those and they were all negative. Really discouraging. Shortly afterwards--so while I 02:03:00was there, we also took serology samples to see if any of her family members had antibodies to the bacteria. It turned out that a good proportion of them actually did. This was another sign that it might have been some sort of contaminated product and most likely it was a product that was being used in the household and not something that she got exposed to in the hospital, for example. We basically had hit a dead end at that point and then sadly a while later there was another case in Georgia--another young child who ultimately died. He had a co-infection with both COVID and the melioidosis. It was in going to this patient's family and collecting samples from the products that they had 02:04:00used that finally the team was able to find the bacteria in an essential oil spray that had been sold through Walmart. Looping back to the other patients it seemed--we weren't able to say for sure whether they had all used this product, but it seemed like at least probably or likely that they had somehow been exposed to it and this was the cause of the outbreak.

Q: Classic epidemiology --shoe leather. I love it. Then you guys put out a paper --and a HAN [Health Alert Network] maybe went out with this telling everybody to avoid this so that no more people would be using this product. It's a great--

KUNKEL: Yes, definitely. Once there was a new EIS officer with the BSPB 02:05:00[Bacterial Special Pathogens Branch] then I have been less involved since then. They've continued to be really busy with, as you said, once the product was identified then putting out all of the communications to share that and working with Walmart to do a recall and testing the products that were still in storage that hadn't been shipped out yet and working with understanding how the contamination had happened. Going back to the plant where it had been manufactured in India and there's a whole lot of steps that they've been taking--both understand what happened and then prevent it from happening again in the future.

Q: Yes, that's wonderful. That's a horrible story but a good outcome of preventing any future. That all happened during when there was the surge due to 02:06:00Delta variant, too. Just an interesting time there. That's got to be kind of a hard one. Do you want to speak any more about your other deployments or should we get to a different portion of this?

KUNKEL: I guess I can say maybe just a little bit about the work I've been doing on MIS-C [Multi-System Inflammatory System in Children] also.

Q: Yes, absolutely.

KUNKEL: That's a project related to Multi-System Inflammatory System in Children which is a rare condition that affects some kids after they've been infected by SARS-CoV-2 then they can develop this hyper-inflammatory condition--it's called MIS-C. There have been people from CDC working on that from very early on in the 02:07:00pandemic and one thing that they did was a study of kids who had been hospitalized with MIS-C at four different children's hospitals in the U.S. just to understand what were the signs and symptoms, and what were the complications that they developed, and what kind of comorbidities did they have, and all those sort of thing. After this study they were interested in doing a follow-up of those kids to see how well they were doing after they had been discharged from the hospital. That's where I got invited to be involved was to work on conceptualizing and then implementing this follow-on study. It started basically right when I got back from the southwest border deployment and has continued kind of part-time ever since then. For me it was a good experience because it 02:08:00was a chance to be working on a project from beginning to the end. To plan the study design, and then work on the protocol, and on all of the SOPs [Standard Operating Procedures], and then take it through the regulatory clearances that were needed, and designing the interview tool, and the chart obstruction tool, and all of that sort of thing. It's also just been interesting, I think--you know, I feel like I've been I guess fortunate to see different aspects of the COVID response throughout my time at CDC. Here, having this more pediatric focus and seeing some of the challenges that are involved in that. Certainly, the risks for children are lower than they are for adults, generally, with COVID but you do have these kids who have these really severe illnesses in some circumstances and in some cases, it's challenging for them to figure out what to 02:09:00do next. For example, is it--if your child has experienced this and you know that they've had this hyper-inflammatory response to their initial infection, should you get them vaccinated or not? That's something that's still a little bit of an open question. I think there's just starting to be more data available and that's some of the data that we're trying to collect from this study as well. There are so many different aspects of COVID that are--raise challenging questions for people and I think people have a hard time knowing what the right thing to do is and this would be one example of that.

Q: This is for children who had COVID and then they experience this afterwards. This is not something that happens after they're vaccinated?

KUNKEL: No, or at least not very often. I think there's been a few cases that 02:10:00have been noted that have been temporally associated with vaccination. I think in most of those it seems like there's also been a COVID infection around the same time as well, but we can't say that it could never be a response to vaccination. What we can say is that there had been some studies to look at does vaccination in children in general prevent MIS-C and that does seem to be the case that, in general, if you are just kind of a general, healthy child that getting vaccination is going to reduce your risk of getting MIS-C.

Q: Let's see, okay. Important work there, too. You're right, your COVID experience is--I want to say all over the place, but you have dipped your toe into a lot of different parts of CDC. I didn't know the pox, rabies gets around 02:11:00so much. I want to turn more to this--to you, actually, and your experience as a--personally and your perceptions personally. You were mainly deployed through teleworking whereas there were others that were just deployed into the field. Can you give me your thoughts on the difference between that because you did both, actually--and which do you prefer, or feel is a better paradigm?

KUNKEL: Yes, I did some of both. I mean, both have value. I think for some projects you don't need to be in the field, it's a lot of coordination, and it's a lot of writing, or data analysis, or that sort of thing--so it's not necessary. I think for me it's more rewarding when you can be in the field, and 02:12:00you can work with people directly and sometimes see the impact that your work is having and create those relationships. I think relationships are an important part of public health and an important part of being human. When you have the ability to work with people in person, I think that tends to be more fruitful.

Q: We had touched a little bit on this, and CDC has really created a push for health equity. We work on health equity throughout most of our divisions. Can you describe any experiences that emphasize the work CDC does on health equity? 02:13:00I mean, you touched a few on it, but if there were others?

KUNKEL: Yes, I mean, I think a lot of my deployments have touched on some aspect of that. The tribal deployment, for example, I think CDC was offering a lot of support to different tribal nations during the pandemic and I think that was really valuable. It was very interesting to me working with the tribe and trying to learn a bit about that and I'm very far from an expert. For example, the tribal nations--they have a direct relationship with the federal government. They don't go through the state because they're--they have this kind of tribal sovereignty that allows them to work directly with CDC and with the federal government and have this basic government-to-government relationship. I think 02:14:00some of my mentors and team leads on the tribal deployments were really had good experience working with tribal nations and were able to teach me about that in a way that was really kind of eye-opening and led me to want to learn more about the history of Native Americans within the U.S., and the relationship with tribal governments, and that sort of thing. I think that's something that I'm--one of the things that I'm probably the most proud of at my time at CDC is being able to support the work that the tribe was doing and feeling like we were there to support it and also have been able to kind of--to share that. I've been 02:15:00working on a paper with authors from the tribe to describe their successful vaccination campaign and show how they did such an amazing job. I think that was really a privilege to be involved in that. There was the--obviously as you touched on--the Emergency Intake Site, but then I think everything in COVID there's always an aspect of health disparity. MIS-C affects people differentially according to racial method group and we see that with COVID in general. I think there's always that aspect of things.

Q: Let me see, could you just talk a little bit about the role of the media on CDC's work throughout the pandemic. Internally as well as externally our media--or communications is a better way of saying that.

KUNKEL: In terms of media or in terms of communications?

Q: Communications--how about CDC's communications with media or the role of media on CDC's work.

KUNKEL: Okay.

Q: During periods of time there were guidance changes --

KUNKEL: Okay. I mean, I would say I didn't have a lot of interaction with the media with any of my COVID work. That was not something that I really had to deal with. I think I was seeing the media about CDC more as a consumer, you know? I would be learning about the changes in CDC policy by reading the newspaper, same as anybody else--which was sometimes challenging. I think I've been on various deployments where we had been telling people one thing was the 02:17:00policy and then there's a big shift in CDC policy, and we didn't know anything about it, and the task force leadership didn't know anything about it, and all of a sudden there's all these questions. I think it might have been when I was at the Emergency Intake Site when the masking guidance changed so that people who were--CDC started saying that if you were vaccinated that you didn't need to be masking. That raised a lot of questions about, well, does that include at these sites, do we not need to be masking, do the children not need to be masking? It was a little bit frustrating because I felt like there weren't answers immediately available and we were trying to figure these things out as much as the people who we were supposed to be the CDC advisors for. That was a challenge, I guess.

Q: That speaks to internal communication.

KUNKEL: One of my sisters is a nurse and so that was also interesting that early on in the pandemic she'd be sending me messages like I hate the CDC, they're telling us that we don't need to wear N95s, and I don't think that's safe. Even before I joined CDC, I was hearing this--starting to hear this sentiment of I don't trust CDC, or I hate what CDC is doing. That is a bit discouraging when you're getting ready to work there and then when you're working here and feeling like everyone is trying to do a good job, but the communications are not always making that clear maybe or sometimes maybe we could do better than we are, I don't know.

Q: Do you think leadership and the change in leadership affected that?

KUNKEL: I don't know. I don't feel like the change in leadership has made a big difference in my day-to-day life so far. Maybe my expectations were a little bit different. I think there's just so much trying to catch up that we haven't really been able to get ahead of it still is I guess how I would put it.

Q: It's very fast moving and a very fast-moving virus. Nobody knew anything about it. I want to just turn to a little bit of your personal life if I can. The impact of COVID on your personal life--did you worry about your other family members. I know you're not all together and when families are not together, they worry about each other naturally. Did this add an extra layer of worry?

KUNKEL: Yes, I think I was worried about my family members. I think what I've been seeing with my family--I'm pretty close with some of my grandparents and my great aunt who I'd mentioned earlier. I think it's just such a difficult trade off because they're elderly and so they're really at risk of getting COVID but they also--we don't know how many years they have left, or how many good years they have left. It's really tough to be--to feel like they're being confined and like we can't see them. For a long period of time, they were basically just being locked down and not seeing any family members. I think my grandfather saw some definite kind of declines in memory and that sort of thing over the last 02:21:00couple of years. It's hard to know would that have happened if he was actually still out and seeing people all the time and active like he used to be. Is that related to just being stuck at home for over a year without having the same kind of mental stimulation or would that have happened anyways. I think that's been something that's been tough, and I think there's not an easy answer to. I also last summer around the Delta wave I think after people were getting vaccinated and the vaccines were doing such a good job it was like this big kind of sigh of relief and we thought like, oh everything is going to get better now. Then I had an uncle who had been vaccinated who ended up getting COVID and ended up being admitted to the hospital last summer and is still feeling some of the effects 02:22:00from that. I think that was a bit of a wakeup call for me that even if we have the vaccines this is not necessarily over and there's still more coming around the corner maybe. It's not quite as simple as we vaccinate everyone and now everyone is completely safe and that's the end of it.

Q: Right, we have the variants to think about. The other thing that you touched on that also brought up I think a health equity problem is age. When you have your grandparents who can't navigate the Internet to even set up their own vaccinations. When we go forward in this, we have to think about that as well--it wasn't easy for any of the older generation to set up any of their appointments so that they could get vaccinated because they're just not of the with your own age where they do everything online. There's a hard thing for them 02:23:00to navigate and I was wondering did you have to do any vaccination care for your older relatives, because I had to do that for my mother.

KUNKEL: Yes, I didn't personally but I think some of my relatives were probably involved in making that happen.

Q: What was the experience with your own COVID vaccination? What was your feeling of--you got the shot in your arm, and you were like, okay I can go back to work now and not wear a mask, or--what was your feeling?

KUNKEL: I actually got vaccinated on my tribal deployment which was I think very kind of them. I was there kind of early January of--well, I guess 2021. They had been vaccinating front-line healthcare workers and then moving on to the elderly populations. I don't remember exactly what phase they were in at that point, but 02:24:00I felt CDC at that point was not seeing us as being front-line healthcare workers even if we were deploying to support the COVID response. I wasn't vaccinated and my team members weren't. When we got there, they offered to use if we would like to be vaccinated because they were, like, look, you're going to be working all of our public health leadership and some of them are elderly and some of them are not able to get vaccinated or that sort of thing. I kind of felt like I was jumping the line almost, that I was getting the shot earlier than I was supposed to. At the same time, I felt like it was a valuable thing to do to be protecting the people who I was working with as well as myself. I was really I guess appreciative of them for giving us that opportunity. I think at the time we were still not sure how much is this going 02:25:00to just protect me and how much is this going to protect other people as well. I wasn't entirely sure how to take it, I think it did make me feel more secure about my health and then once my--I was really happy when my grandparents were getting vaccinated and shortly after that when we were all vaccinated, I drove up to see them in Ohio for the first time in I think more than a year. That was just really great to be able to do that which hadn't felt safe enough to do until that point.

Q: Yes, it did give a sense of freedom to move about a little bit more and then Delta. You did tell me about one of your family members who became sick. You also talked about a Cambodia testing story when we pre-interviewed. Did you want to talk about that now?

KUNKEL: Sure, I can talk about that. That's when I was in Cambodia and working on the response and it was really interesting working in Cambodia on the--in these early months of the response and then comparing the response there with what was happening in the U.S. because it just seemed like testing was going to much better in Cambodia. There were still strict rules about who could get tested, it wasn't open to anybody, and they were mainly leaving it to people who had had international travel or had contact with somebody who had--but if you met those criteria and were approved for testing then you could get your testing results within a couple of days. All of the testing was happening at the Pasteur Institute at the beginning, and I wasn't--that was kind of an aspect of it that 02:27:00I wasn't as involved in because I'm not a lab person, but it was a huge effort that they set up all of this testing. They were very prepared and able to do--just take on a really heavy testing load from a stage where the U.S. was still really struggling to ramp up testing. After I had started working with the COVID response team in Cambodia--after maybe a couple of weeks I started to feel sick, and I had kind of cold like symptoms. I was coughing and sneezing and maybe had a low fever or something. Once I knew I was sick then I started staying home but then it was really kind of lingering on, and I was even a week later still coughing and kind of needed to be in the office working. I mean, at that stage we were--everyone was going into the office, we were all working in 02:28:00this big conference room together, nobody was even wearing a mask for the most part. I had this feeling like, oh my gosh, if I have COVID I could have just infected the entire contact tracing team of all of Cambodia! Which was not a great feeling and I had been on this trip with my friend who was from France, and I thought what if we got it on this trip. I was still coughing a week later, and they were nervous about me going back so finally with Mike Kinzer and I and then the people at Pasteur decided I should just get tested. Luckily for me because I worked at Pasteur, and I knew all the people there and they were the people doing the testing they basically gave me like the VIP [very important person] treatment so somebody actually came to my apartment to do the test. I had to say to her ahead of time--I was, like, please don't put on all the PPE before you come in the building because people are going to be really scared and 02:29:00I don't want them to be freaked out and she was, like, no, no, no I don't think we need to do that. We kind of arranged it that my roommate let her into the living room and then she got--donned all the equipment and then came into the bedroom and swabbed me and then went back out and took everything off. That was a, yeah, I guess just like a moment of making it seem really real is, wow, here's this person in full PPE who is in my bedroom here to swab my nose and see if I have COVID. I wasn't worried about myself really, but I was worried about all of these people who I was working with. Yes, yes. Then, you know, she took the swab back to Pasteur and they tested it I think that same day or the next day and I got the result, and it was negative so that was a huge relief, and I was able to go back to work. From that point on I think CDC was still saying you don't need to wear a mask, but I started wearing one every day basically because 02:30:00I thought, you know what, if I do have COVID and I don't know about it I don't want to put all these people at risk, and I'd better be taking precautions. People in Cambodia in general are more open to wearing masks and maybe even before that I had started wearing them just like outside when I was going grocery shopping or when I would ride in the Tuk Tuk because I had the feeling that it just made people feel more comfortable. There was definitely some sense that people were afraid of foreigners for--at that time, like I had mentioned with my friend who was Chinese--originally there was some fear there but not towards me but by March or April that was directed towards me as well because there had been now many foreigners who were white from different countries who had COVID. Sometimes you would get in a Tuk Tuk, and the person would spray your hands with who knows what kind of alcohol solution and just be spraying everywhere around you and trying to keep you from--making sure that you weren't 02:31:00infecting anything. Wearing a mask seemed like the right idea at that point just to make people feel more comfortable. I do think actually that, I mean, that was something that was quite frustrating about the CDC response is that I don't think there was any--I feel like they had just been so clearly saying that you do not need to wear a mask and I feel like that should have been a little bit more--at least not quite as categorical against it because I felt like they were really telling me don't do this and that wasn't--it wasn't clear to me why you would say that, it wasn't clear what the harm would be and why I wouldn't wear a mask, and obviously that guidance ended up changing later on. Another thing that I realized was there was a period where there was a team from China that came down to advise the government in Cambodia about COVID and we didn't interact with them. I didn't interact with them very much. One thing was 02:32:00that they were all wearing masks the entire time and they were I think shocked that we were not and kind of like concerned about meeting with people not wearing masks. I think maybe that's something that we should have been a little bit more open to learning from the Chinese experience that if they felt like masks were a really important part of their response that's probably for a reason and what can we learn from that. Since then things have changed, obviously, so that we are recommending masking here as well.

Q: Yes. Coordination. All right, we're going to get to our reflective area now and you kind of touched on this a well--the effect of COVID on CDC's reputation and public health as a whole. How do you think COVID has affected both of those?

KUNKEL: I think not in a good way. I think it's been pretty discouraging working in public health. I mean, I think everybody gets into public health because they want to feel like they're doing something useful and like they're making a difference. I think sometimes I've been able to see that in my work and sometimes it's felt like that's a little bit harder to see. I think CDC always had kind of such a great reputation before and that was part of why I was kind of excited to join EIS and be a part of that. I feel like that's not so much the case anymore. I don't necessarily want to tell people I'm working at CDC and, I mean, one thing that has changed for the better is that if I tell anybody that I'm an epidemiologist now anybody knows what that is so it's not like--they're not asking me anymore, oh are you a skin doctor, what does that mean? I 02:34:00guess that's been one benefit. Yes, I think, I guess with epidemiology, you're with public health--it's a little bit--it's easier to understand than virology or something. Anybody can think that they can be an expert in epidemiology and in public health when some of the nuances end up getting lost in a way that probably not anybody thinks that they can make a vaccine. I think probably public health takes a little bit of a beating from that. I also think there's this side of--that I guess I hadn't thought of so much before--that is the relationship between public health and politics which is that you can be an expert in public health, and you can make the recommendations that you think are best from that standpoint but it's not you who's necessarily making the final 02:35:00decision. Then it's also not--I don't even know if it should be, even--some cases like you're making the best decision based on the public health but there's other things to consider as well. I think about, for example, when I was on the tribal deployment, they were trying to make some decisions at one point--the tribal government--about whether they should lift their semi-lock-down or not. On the public health side, I think the--at least on the COVID public health side--the concern was that it was too early and so maybe they weren't ready to do that yet and that sort of thing. Then later in the day they had people coming from the police department who were saying, well, we're really concerned about rises of domestic violence and that sort of thing. There 02:36:00are these other things that need to be considered alongside just pure public health which is the domestic violence, or the mental health, or the economics. There are just many aspects of things that if you're using it just to kind of what's best for preventing COVID infections maybe you're not seeing the whole picture.

Q: Right, a holistic picture, yes.

KUNKEL: Yes.

Q: Well, that brings me to the effect on people's mental health, too. You guys, as EIS officers, are constantly on the go and there's got to be a bit of burnout and hopefully there's some recovery there. Can you speak to that?

KUNKEL: Yes, I mean, I think the last few years have been really difficult for everyone. I have definitely felt that myself. I think sometimes you find ways to 02:37:00make it work and there's periods where infections are lower and so you're able to see friends and then the weather's nice so you're meeting outdoors or you're going hiking. Then there were periods where the weather's terrible and the infections are high, and you can't see anyone for a long period of time and that's challenging. I think with, you know, it's been really hard to establish a social life and to feel kind of like a complete person here. It's like everything that I'm doing is in my apartment and everything that I'm doing is work, almost--or it's work-related because when you're working on COVID you never get away from it, you know? It's part of your personal life and it's part of your work life. I think that's been hard, it's been, yes, hard to feel like I 02:38:00really have a community here in Atlanta and I think that's probably part of why I decided to leave after EIS is that it doesn't feel like home still. Yes, it's been a challenge, I think, it's been a challenge for everybody.

Q: Yes, a lot of people are calling this the lost years, and when we look back on this and see how many lives have changed--lots lost because they were not able to, let's say, graduate, go to their own graduation, experience their last year of senior high school in person, and all of that. The line between work and life, as you said, has become blurred. It's like, when does your life at work stop and when does it start? Are we going to go back to a nine to five job kind of world? It's completely thrown a lot of our own social norms into a different 02:39:00world. So are--are there--I'm sorry, go ahead.

KUNKEL: No, I'm--that's okay that's fine, I don't know if I have much more to say.

Q: Okay and are there any more details about your job and your experiences or background right now--do you want people to know?

KUNKEL: I realize that I forgot one thing that I think you had asked maybe a two-part question and I forgot the second part which is about quarantining. When I was traveling--so when I traveled from Cambodia to France, I think I did not need to quarantine. I went from Cambodia to France and then I stayed in France for about a month and then I came to the U.S. from there. The EIS program told all of us who were coming from abroad that we would have to quarantine for two weeks before starting EIS. We had to plan a way to do that and originally, I think they weren't going to even really assist, and I think eventually they were 02:40:00able to do that and help people who didn't have somewhere to go. In my case I was able to go to my parents' house in Virginia and they set up--they had these two connecting bedrooms upstairs that also had a bathroom and they put in a little mini fridge, and they put in a microwave and stuff. They called that the quarantine suite. I got to spend two weeks in the quarantine suite at my parents' and they kept the quarantine suite open for, I don't know, six months or a year or something so that anytime somebody would be coming in from a trip and would need to quarantine they would go in the quarantine suite. I think many of--I think me, and my dad, and maybe one or two of my siblings have all kind of passed time in the suite. I mean, yes that was just a crazy thing that you wouldn't think about before COVID. It was nice to be with them because they 02:41:00have a house, and they have a porch and so we would have sometimes lunches or dinners on the porch, and they would sit on one side and then I would sit all the way on the other side so we could see each other and talk to each other but there was still plenty of distance and airflow between us. Then as I had mentioned my sister is a nurse so she was living in the same city as my parents during the early parts of the pandemic, but they hardly saw her because they were worried about the fact that she was seeing COVID patients, and could she bring it home, and that sort of thing. Her, too, the only way that she would be seeing my parents would be maybe having dinner on the porch and she'd be sitting on one far side, and they'd be sitting on the other side. That was just the way that we did things until people started to get vaccinated, I guess.

Q: Yes, there were different rituals that each family had. When you would come 02:42:00home people would spray down their groceries, people would spray down their clothes, change in the basement, come up. All sorts of different rituals. Then, once again, yes, as you said--once the vaccine had come into place then it sort of opened up and then--just a nicer time. You got to see more people. What about your other siblings? Where were they during this time?

KUNKEL: Yes, I have one who's in California and one who was in Wisconsin during that time. I think we just all did lock-down at home and work from home and don't see many people phase for a while. It was a while that we didn't see each other.

Q: Did you have family Zoom calls?

KUNKEL: We did some of that. I think more my parents and my grandparents got into it. I think for some of us it was like we were doing so much Zoom during 02:43:00the day that doing a Zoom call doesn't sound very fun.

Q: Zoom fatigue, yes. We're coming to the close here, we've spent two hours talking. Can you tell me what--if you had--the biggest professional, personal challenge that you faced during the pandemic--what would that be?

KUNKEL: I don't know, I mean, I think for me the pandemic was sort of in two different phases. There was the Cambodia phase and then there was the U.S phase and those were just really different. Thinking about Cambodia it was really--it was more of that kind of urgent feeling to the response where you're really kind of rushing to try and stamp this out and you're not sure what the risk is to 02:44:00yourself and I wasn't sure am I going to be able to leave Cambodia, am I even going to be able to start EIS, or will I maybe be late to start EIS and hopefully they'll be okay with that. Just kind of all of the personal questions and things that were associated with that were really challenging. Then I think after I moved to the U.S. then it was this other sort of phase and where it was a lot of, as I said, sitting in my apartment by myself alone all the time. I think that has been the tough thing for me is just the lack of human contact and connections and those things that remind you that you have value as a person outside of what you're doing at work. If you're living by yourself and you're just working on your computer and that's the main way that you're seeing people sometimes that's hard to remember. That's what I would say for the second part.

Q: Did you start baking bread or did you do anything that you didn't--adopt a puppy or anything like that, but--did you find that you had to do puzzles or something. A lot of people got into some sort of side-gig.

KUNKEL: Yes, I mean, I tried some hobbies. I don't think I stuck with any of them super well. I did a little bit of piano that I had never done since I was a kid and that kind of thing. It was harder to do things consistently. I think particularly during the first year what I really did was--well, for one thing I did go visit my parents a few more times during the--even before I was vaccinated, and I would just basically isolate at home for two weeks and then drive up there so I had really low exposures and 02:46:00everything. That was part of it. The other thing is when I got to be really too much to just be sitting at home all the time then I would try and do a field deployment. That was another thing that kind of kept me going, I guess.

Q: Did you get outside and walk and enjoy--

KUNKEL: Definitely.

Q: --yes. Did you ever get that feeling when you pass somebody on a path that, oh my God am I going to get it because I just went through his--and they weren't wearing masks and there was that whole time where you just didn't know and you avoided everybody.

KUNKEL: A little bit. I mean, I think I missed some of that because I think a lot of that was kind of in the March, April, May--in certain places. In Paris--Paris was completely locked down and like my friend who was there was--it was like he could--you were only allowed to go outside for exercise one hour a day, you had to bring a signed form with you saying where you lived and when you 02:47:00were going running, and it could only be within one kilometer of your house. I mean, it was so strict! I really missed that whole period, so I was in Cambodia and Cambodia was pretty open because the cases were not that high. Things were not--I was still going into work every day, towards the end I was going out to restaurants and things, even, because there were--the risk was just really quite low. I feel like fortunately I missed some of that early phase of that kind of fear, I think. I still had some of that, I think, maybe in Paris and then here that summer--but yes, like you mentioned, I guess the one thing that I have taken up that I hadn't done much of before is hiking. That was not something that I did very much of and that just turned into my main pandemic activity that I'd try and find somebody to go with me every weekend or something just to get 02:48:00out of the house and see some nature. That was a nice thing to pick up and that's the nice thing about Atlanta is there are so many trees here and you feel like you really can get into nature and get away from things.

Q: Yes, that is nice. All right, well we have come to the end now. I'm going to ask the last question. What else haven't we covered that you'd like to share?

KUNKEL: I think we've covered everything.

Q: All right, well good. I'm glad we had this chance to record and thank you very much!

KUNKEL: Thank you!

[END OF INTERVIEW]