Robert Bonacci - Session 1

Q: Today is Wednesday, June 22, 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 to Robert [A.] Bonacci who's also in Atlanta, Georgia, and we are according through Zoom. Rob, do I have your permission to interview you and record this session?

BONACCI: Yes, you do.

Q: For the record, can I ask you to say your name and then tell me what your current position is with CDC [Centers for Disease Control and Prevention]?

BONACCI: Absolutely. My name is Robert Bonacci, I'm an Epidemic Intelligence Service [EIS] officer on the Prevention Research team of the HIV [human immunodeficiency virus] research branch in the Division of HIV Prevention at CDC.

Q: Okay, thank you so much for being with me. Before we delve into the whole details of your path to CDC, can you just tell me a little bit about your family background and the community where you grew up?

BONACCI: Absolutely. I was born in Cleveland, Ohio, but was raised in a suburb 00:01:00of Akron, Ohio, called Bath. I am the oldest of five children, so I have one younger brother and three younger sisters, and my parents, Mario, and Carol, are both particularly influential I think in the early part of my life. I would say in terms of the neighborhood I grew up in, I grew up in a pretty typical suburb of Akron. It was in between Akron and Cleveland. It was a pretty quiet childhood for the most part. I think one of the perhaps unique things about my family growing up is that my mom and her family emigrated from Mexico when she was a teenager, and then on my dad's side of his family, his father had emigrated from Italy earlier, I think shortly after World War II, and so we have a relatively young history--young family history here in the United States. I think that was always something that stuck with me, particularly the challenges of--that my mom and her family faced as recent immigrants and in general having family members 00:02:00who have recently immigrated at different times in my life. I think that was particularly impactful growing up and raised an awareness within me of those issues from an early age. Similarly, over time as I was growing up, I began to develop a greater appreciation for my cultural heritage and the unique and special histories that my family have and so those were, you know, some of the touchstones of the early years my life that I think have been influential throughout.

Q: We've had one pre-interview before this day, and you had mentioned that your mother was an interpreter in a healthcare setting. Can you describe what that was like?

BONACCI: Yeah, so in the early part my life, my mom stayed at home to take care 00:03:00of us and raise my siblings and I, but sometime probably around middle school for me or it was probably around middle school, she started going back to work and was working as a Spanish language interpreter in, initially the criminal justice system, and then for a longer period after that, in the healthcare systems around our area, particularly in the hospitals in dealing with obstetrics and gynecology and women who were getting ready to give birth or have given birth recently. For me, thinking about my cultural heritage and the history of recent immigration my family and then my mom's work as an interpreter in healthcare settings, when I think about some of the early influences in my life and what pushed me to become interested in public health and medicine and particularly the larger social context that we live in and some of the issues that immigrants face, her work was really formative in that. Specifically, it 00:04:00was through seeing her experiences and her getting to know many immigrant families whether they were documented or undocumented and the particular challenges that they face. I should say that those immigrants were all Spanish-speaking immigrants, primarily from Mexico, but from Latin American countries in general. Again, I think that was a really early, informative period of observation for me, yes, just getting to understand a bit more again about the challenges they faced. I think it was, in a way, not explicitly but perhaps by osmosis or just observation, my first introduction to issues of social inequity and social justice as well. So, my mom is a Spanish speaker, dual-language, Spanish and English speaker. We didn't grow up speaking Spanish 00:05:00in the house because my dad only knew English, but we were always around Spanish language whether it was through television shows or music or other cultural-related things. For me, even though I didn't grow up speaking as a young kid, it became more--increasingly more important and a focus of mine to learn Spanish both as a personal interest, and what I thought in a future career in either medicine or public health would be quite useful to have a second language, and particularly Spanish here in the United States.

Q: You are a Spanish speaker now?

BONACCI: Yes.

Q: That's great. Let's turn to your academic background. You went to Ohio State University?

BONACCI: Yes, so I went to Ohio State University for undergrad. I was there from 2006 until 2010, that's correct.

Q: You told me that you were a Fulbright Scholar as well and visited Mexico?

BONACCI: Yeah, so after I finished--at Ohio State, I majored in microbiology and 00:06:00Spanish and spent some of my time studying abroad in Argentina while I was in college, in part to continue to improve my Spanish. It was during that time at Ohio State that I knew I had an increasing interest in global health, in medicine in particular. I think through high school, I knew I was interested more broadly in the biomedical sciences, but as I got to college, I--that interest narrowed more specifically to medicine and wanting to become a physician. Some particularly influential things that I had read at the time, learning of the work of Paul [Edward] Farmer in Haiti with his organization Partners in Health and reading the book that was written about him, Mountains Beyond Mountains: [The Quest of Dr. Paul Farmer, A Man Who Would Cure the World] was a particularly inspiring experience that helped to catapult my interest in global health and I think helped to raise awareness of what health equity was 00:07:00and social injustices that many populations faced.

Again, while I was observing these things as a kid, I don't think I had a language or a framework to understand this and started making connections between some of the things that I was reading in Paul's work and other people's work and some of things I had observed perhaps not in my own life but through my life and the life of others. As I became more interested in medicine, I got involved in tuberculosis [TB] research at Ohio State in a lab. At the time, I was considering a medical degree and potentially doing a PhD and what I learned from that experience was that I really loved tuberculosis, the organism, and found it fascinating. This is a disease that has been around for thousands of years since the time of the Egyptians or earlier. But I realized I didn't love being in a laboratory and so where this is going and what led me to my Fulbright experience was that I was really interested after college in getting into more 00:08:00of the public health side of tuberculosis and moving a little bit out of the lab and into more epidemiology. So, I had applied with a research group, a TB research group in Cuernavaca, Mexico, at the Instituto Nacional de Salud Pública or the National Institute of Public Health for Mexico. I spent a year down there working with the group studying the impact of tobacco use, particularly cigarette smoking on tuberculosis and TB treatment outcomes. That along with many of my college experiences I think were particularly formative in my journey to becoming a physician who works in public health and specifically that has spent a lot of time working in HIV and TB since then. I often joke that TB was my first love in terms of my academic interest, and that was really fostered early on as an undergraduate and then as a Fulbright Scholar in Mexico.

Q: Thank you, wow. So, after your bachelor's, you go to become a physician or get into the school of medicine in Perelman School of Medicine--in Philadelphia? That is a little bit further away from Ohio State.

BONACCI: Yeah, exactly. After finishing my Fulbright, I came back to the medical school at the University of Pennsylvania, the Perelman School of Medicine. I was there from 2011 until 2016. And again, I think coming from college early on, I had a pretty good sense that I was interested in global health and infectious diseases and so coming into medical school, the pathway that that would take me into residency and specialty training afterwards was likely going to be internal medicine. I came in pretty interested in that, and I think throughout the four years of training in medical school, I continued to be extremely interested in the areas of global health, public health, HIV, and tuberculosis and their 00:10:00intersections particularly with health inequities. So that led to some of my work in medical school, which was primarily focused on HIV and so it was a mix of I was doing some policy-related work related to US HIV policy and then I was also doing some HIV epidemiology work related to looking at medication adherence and retention in medical care for patients living with HIV.

Similarly, another important touchstone or moment in medical school was that that was where I met my wife [then partner], Nicole [Herbst]. She and I were classmates in medical school. Eventually, she graduated before me because I ended up taking a year out in between my third and fourth year of medical school to pursue my Master of Public Health at Johns Hopkins University and so that was 2014 to 2015. I basically took a year leave from medical school to go do that 00:11:00and then came back and finished my last year of medical school afterwards, but she went straight through. So, she finished medical school a year ahead of me and then beat me up to Boston [Massachusetts]. For me, the master of--Master of Public Health-- was, again, a continuation of developing an interest and building expertise and just learning more about the world of public health.

In medical school, we have a little bit of exposure to public health coursework or training, but it's certainly not the focus or the primary focus of the curriculum. I was really interested in pairing my clinical training with, you know, building public health expertise and learning more about public health and so that--I found really an attractive opportunity to be able to go to the [Bloomberg] School of Public Health at Johns Hopkins and to study epidemiology and biostatistics, and that's really where I picked up the HIV policy research piece of the work that I was doing. Again, I think the unifying thread 00:12:00throughout all of this was thinking about the intersections of infectious diseases, HIV and TB in my case, and their intersections with disproportionately affected communities or populations and their intersections with health equity.

Q: Was there somebody that inspired you to get your master's in public health? To stop right then and there, and take that break and get your master's and come back? Was there a moment in time or something that happened?

BONACCI: Actually, I'd come into medical school pretty interested in doing either a joint degree program or taking a year out from a particular medical school to go get my Master of Public Health. Once I had been in medical school, this was already something I had been interested in thinking about for a while. But again, I go back to probably when I was an undergraduate student at Ohio 00:13:00State and when I first read about Paul Farmer's work and understood a little bit more about the work of Partners in Health, the organization he founded, as a real catalyst of my interest in understanding more about the intersections of the social, political, economic, and structural environments and their intersections with health and how so often, a person's ability to attain their highest state of health and wellness, in many cases, often has less to do with their individual behaviors and much more to do with those contexts, the social, political, economic contexts that they live in, work in, or raise their families in. I just became really interested in that, sort of I think trying to understand the world a bit more, particularly the medical world, a bit more from that perspective and so it was his work and the work of others that inspired me 00:14:00to pursue this path.

I saw public health training, an MPH [Master of Public Health] as an integral step or another piece in advancing that training. So, there was the clinical work, which in medical school was getting the basic clinical training for--but then also, I spent a lot of time as a medical student volunteering at a clinic in South Philadelphia called--so a community organization and clinic called Puentes de Salud or Bridges to Health. This was an organization founded by some of my mentors at--in medical school and specifically served primarily Spanish-speaking, undocumented immigrants--undocumented and documented immigrant population in Southern Philadelphia or South Philly. The majority of the patients we served were Mexican immigrants, but again, many of them came from across Latin America as well. That for me in medical school was providing a different type of education while I was in my coursework and working on the 00:15:00wards in the hospital building some of that clinical expertise and that foundational clinical knowledge to get ready for residency.

I was doing clinical work volunteering at the clinic, but I think the lessons I was learning there were much more important than the clinical skills themselves. I was learning from our community members, our patients who live there about the different struggles that they faced in their lives as, in many cases, undocumented immigrants whether that was struggles with poverty or struggles with employment, struggles with language, struggles with racism. Similarly, on the side of the--my mentors who ran the organization, I think I was learning a lot about social consciousness and morality in medicine or a moral practice of medicine and found that working alongside of them to be really transformative in the way I thought about the role of a physician in the community. Both in terms of again what factors influence the health of our patients that we're taking 00:16:00care of, and also what our role could be beyond the clinic or the--either the exam room or the hospital and how health bleeds into all of these different facets of life. I saw those physicians really take an active role in trying to address what we now call and what are known as the social determinants of health and building programs that weren't just focused on the clinic itself but building early education programs for the children of the parents we were seeing in the clinic, building art programs, building counseling programs. I think that was particularly transformative in the medical school side and then pairing that with my public health training, understanding more about the epidemiology and the study of health of populations and getting a broader context, a sort of more zoomed-out context on medicine and health in the United States and across the 00:17:00globe. That's where my interests in those two-degree paths intersected.

Q: I can see that, yes. That's an incredible way of looking at the wholistic part of being a physician, not just treating the one virus, disease, or whatever, but also what is causing in the social determinants of their health, yes. Hold on a minute. [INTERRUPTION] I had to pause as some people came into the room.

BONACCI: No worries.

Q: Where were we? Oh, yes, your master's was at Johns Hopkins, and this is where you're exploring not just clinical lessons but also community and trying to 00:18:00understand the community that you're serving, which is not from the book but also from the heart. So, what happens after that? You go on to Brigham and Women's Hospital in Boston because that's where--is that where your wife is at the time?

BONACCI: Yes, that's where my now wife matched. She matched for residency at Boston Medical Center for internal medicine and so, yes. I finished up my MPH at Johns Hopkins-- I came back and finished my last year of medical school in Philadelphia. Maybe one experience I'd mention there that I think was also important for me was that I spent six weeks at our clinical site in Botswana. The University Pennsylvania has long partnered with the Ministry of Health and the government of Botswana. Particularly, this started more around the rise of the HIV epidemic in Southern Africa and so I think that's where the relationship began but I spent six weeks doing clinical work on the wards there and seeing patients at the HIV clinic and in the male and female medical wards. Again, I 00:19:00knew I had been interested in global health and this was among--in addition to working at Puentes de Salud, which in its own way, I think very much embodies this, the spirit of work at intersections of health equity and global health, working in Botswana was a similar type of experience but in a different environment. It was my first-time spending time in that part of the world and so, yeah. Then, I graduated medical school in 2016, and I started as an internal medicine and global health equity resident at Brigham and Women's Hospital in Boston, which was for me a four-year residency program. So internal medicine training is usually three years in length for most folks, but because I pursued this additional global health equity residency track, which was something that was offered at Brigham, it adds an additional year to training. So in addition to doing the full three years of training in the United States in the hospital wards and having a primary care clinic at the hospital, I also spent a 00:20:00significant part of my time as a resident traveling and doing international work.

Our residency partners with Paul Farmer's organization or the late Paul Farmer's organization, Partners in Health, and we had the opportunity to work at the clinical sites. Partners in Health works in more than ten countries across the world, primarily in impoverished areas and often rural areas, so countries like Haiti, Malawi, Lesotho, Rwanda among many others. I spent a lot of time as a resident also getting to work at those clinical sites. The places where I primarily spent my time were in Lesotho and Malawi. Initially as a resident, I was spending more time in Malawi, which was where I was working on general quality of care issues around tuberculosis care in the hospital and was also seeing patients on the male and female medical wards, so seeing general medical patients with the staff of the hospital in a two-way exchange. I think they were 00:21:00teaching me about many of--the management of many of the conditions that they see that we don't see as often in the US or at least in my residency program, so things like malaria, which they would see quite frequently or advanced cases of HIV or tuberculosis, which weren't as common--commonly seen in the hospital where I trained. And then similarly when we were seeing a lot of, what I would say as, bread-and-butter kind of core internal medicine cases, things like heart failure or heart disease, diabetes, et cetera, liver disease, I was also able to mentor and share what I had been learning in residency with some of the clinical staff at the hospital. It was this fun process where we were both learning alongside each other and sharing expertise based on what the most prevalent health conditions that each of us see in our training are.

Then after spending a lot of time in Malawi and working on some quality of care 00:22:00around diagnosis of tuberculosis and screening for tuberculosis in the health district that we worked in there, the Neno Health District, I transitioned some of my work to Partners in Health in Lesotho and was working in the capital Maseru. PIH [Partners in Health] Lesotho helps to run the drug-resistant TB treatment program on behalf of the ministry of health of the country and so I went down. I was very interested in learning the medical management of drug-resistant tuberculosis, which after many decades of pretty dormant medical progress in the treatment of drug-resistant TB, recently in the last five to ten years, there have been some pretty significant medical breakthroughs in terms of new medications and drugs to treat drug-resistant tuberculosis, and I was very interested in learning some of the medical management of those drugs.

Partners in Health had been participating in--or leading a clinical trial to study some of these new drug regimens. As background, drug-resistant 00:23:00tuberculosis treatment often took anywhere from eighteen to twenty-four months, sometimes longer, usually involved historically--a daily injectable medication, which had pretty high rates of kidney damage and hearing loss and other morbidity and side effects. So, these treatment regimens were often quite difficult for patients to take both because of the length and the side effects. And the mortality of drug-resistant tuberculosis was quite high, in many places as high as seventy to eighty percent and so the need for improved all oral drug treatment regimens was really, really marked. The fact that some new drugs had finally come out after decades and decades of lack of clinical development was really exciting. I again was down with Partners in Health Lesotho primarily to learn to use some of those new drugs in how to treat drug-resistant tuberculosis 00:24:00in a new era for the disease. I think what we found, anecdotally just from working on the wards at the Botšabelo drug-resistant TB Hospital, was that we saw patients making marked improvement. We saw mortality rates decreasing, we saw side effects decreasing, and I think that was just a really interesting opportunity. I'm really grateful to have learned from my colleagues who had developed that expertise there, and again was another really important piece of my learning and education as a physician and as a global health resident.

I think one of the other nice things from an educational perspective, but one of the challenges from the PIH or country perspective is that the majority of people with tuberculosis or drug-resistant tuberculosis in Lesotho are also co-infected with HIV, and so it's not just managing one disease but both of these often. I think about seventy to eighty percent of our patient population 00:25:00is also co-infected with HIV and so we were to deal with the challenges of both but found those to be really incredible opportunities to learn and to meet colleagues and develop friendships and relationships around the world and to understand what the Partners in Health model of care and the organization's morals in action or values in action look like. I think those have been really of beneficial lessons that I have taken from those experiences as a resident.

Q: So, to clarify, people living with HIV usually are more likely to become--get TB because of their weakened immune system, is that correct?

BONACCI: Yeah, that's correct, and for countries like Lesotho or Botswana where I was earlier, it's a combination of a few things. One is that the rates of HIV, particularly in the southern part of Africa and in many of the southern 00:26:00countries there, the rates of HIV are very high and access to HIV treatment was very delayed compared to access to HIV treatment in the United States. That's for a number of reasons, but one is that the cost of drugs was exorbitantly high and not enough effort and attention was focused on providing affordable medications and providing equitable access for these countries to antiretroviral therapy for HIV. I think another piece of it is also that the incidence of TB is higher in these countries, much, much higher as compared to the United States. So not only do you have a much higher background tuberculosis incidence in these countries but then you also have a more vulnerable population in the sense that HIV is more widespread. Then particularly advanced HIV, which is, as you were asking, comes with a higher degree or increased immunosuppression, leads to tuberculosis infection being more likely to develop into severe disease. TB when 00:27:00it develops into tuberculosis disease is quite deadly and so TB globally is--but at least before COVID [coronavirus disease 2019], COVID has changed a lot, but TB was the largest infectious disease killer in the world, and often that was in patients living with HIV. We were, certainly in Botswana, in Lesotho, in Malawi, was often seeing the effects of both of those co-occurring epidemics in the patient population I was taking care of.

Q: Why are the HIV rates so high?

BONACCI: I don't know that I'm the best acquainted with the full history, but I think one--a few reasons or one that there was an under--a vast underappreciation of the burden of HIV in various countries on the continent early on. Because there was an underappreciation of the burden of HIV, then there wasn't--there also weren't sufficient resources for testing and diagnosis, 00:28:00there weren't sufficient resources directed towards treatment. HIV took hold in these populations, particularly in young heterosexual adults in these populations, and spread rapidly because one, patients or community members weren't aware of their diagnoses and two, access to treatment, particularly in the late '90s and early 2000s, was extremely poor in many of these countries. Again, I think the reasons for those are quite complex and stretch all the way back to the United States and to western countries as well in terms of not ensuring that these countries had equitable access to medicines and particularly at rates that they could afford. Also in many cases, the health systems in some of these countries that had been impoverished over time from extractive colonialism, I think the health systems weren't operating all that well in many of these areas, particularly in the harder-to-reach parts of these countries. 00:29:00Like in the rural areas of Malawi for example or in the rural areas in the mountains of Lesotho, it's difficult to provide care in these areas and so if there's not resources to be able to do so, if there's not staff, if there's not clinic space, if there's not stuff, the medications, the diagnostic testing, and if there aren't systems to be able to reach these individuals, then those are the conditions under which HIV can spread undetected. I think that's a large--without hitting every point, I think that's--touches on some of the reasons that the HIV epidemic and that honestly, it's quite similar for tuberculosis there, why rates were so high there. In the United States in 1995 and in western countries, the first three drug regimens for HIV were reported on in clinical trials, and the success rates were quite hopeful, and it ushered in a new era of HIV treatment that hadn't previously been available to individuals. 00:30:00While the treatment involved a lot of pills and a lot of side effects, this treatment could be life-sustaining.

It took many more years for those scientific advances and that research and that drug development to reach a lot of these countries. As I think about my work in public health and think about the work that we all do, that's a lesson that or that's a history, I should say, that sticks with me often is I think just the underappreciation of the epidemic there, the lack of political will and effort to provide the same level of care and resources that were available to us here in the United States and European countries to countries on the continent of Africa that were suffering significant HIV epidemics. These countries continue to feel the reverberations of that years and decades afterwards because again, 00:31:00HIV is something, as you know, that you live with for the rest of your life. It's a highly treatable condition under the right conditions with the right medications, but it's not something that you--there's no cure for it and so it sticks around for a long time, and so, yeah.

Q: Yes, it's gone--it used to be a death sentence when you got that diagnosis, and now--it's a chronic-type disease now.

BONACCI: Yes.

Q: Interesting. Were you in Malawi and Lesotho for long periods of time, is it years, or were you just coming and going--not we, you?

BONACCI: Yes, it was a lot of back and forth, so it was over the three and a half or four years of residency training that I was going back and forth. I was usually going for a month to a month and a half or a little bit longer at a time, anywhere four to seven or eight weeks at a time. In my first couple of 00:32:00years, I was usually spending about three months out of the country in terms of my training obligations back in Boston and then my last two years of residency was about the half year spent in those sites in Malawi, in Lesotho, and then about half the year spent Boston. That was because the design of this unique global health equity track that we had at Brigham and Women's Hospital, which allowed us to do--to spend time in both places. We had these minimum requirements that are set by the ACGME [Accreditation Council for Graduate Medical Education] or the overseeing organization of medical residency programs, and they require so many months in certain rotations based in the US. None of the work that I was doing outside of the country counted towards those minimum requirements and so it was--that was part of the reasons for having to go back and forth over time repeatedly.

Q: Yes. You were there long enough to really create some sort of relationship and trust with the people that you were working with too?

BONACCI: Yeah, absolutely. I think honestly that's one of the most rewarding 00:33:00parts of doing that kind of work, particularly when you're able to do it for more than just a limited one-time experience. Over a few years, I was able to build friendships with colleagues in Malawi and Lesotho and elsewhere. They're people that I still keep in touch with on WhatsApp to this day and who I had learned a great deal from both about working in impoverished settings, working in rural areas, in areas where it's difficult to provide medical care, working with patients that are often quite sick with tuberculosis. They taught me essentially everything I know about the management of TB and drug-resistant TB and so, yeah, that's absolutely one of the most rewarding parts. I think I probably learned a lot more from them than I was able to share with them, but similarly, since a lot of the physicians who work in these countries aren't necessarily subspecialized or trained in a particular specialty, they're more of generalist physicians, whereas I was learning specifically internal medicine, 00:34:00often I would try and share and exchange some of those tidbits or things that I was learning about, again the management of classic internal medicine conditions, which these patients also had often. Some of the joy of being able to do this work alongside colleagues is that exchange of knowledge between each other. Yeah, no, they're friends that I appreciate and feel grateful to have met and to continue to be colleagues with.

Q: You were able to get out into the country and get away from your clinics and see a little bit more than just the clinic?

BONACCI: Yeah, that too. For me, I've always loved to travel and see new places and meet new people and experience new cultures and cuisines and things like that too and so it was great to be invited into their homes and to learn more about what their typical meals were like, and also get to see some of the 00:35:00beautiful parts of the country. Lesotho is situated, the capital is about a mile high in the mountains and sits in the Drakensberg Mountain range, and it's surrounded on all sides by South Africa. There's a lot of really pretty places to visit in Lesotho, a lot of beautiful nature with the mountain range there.

Q: Oh, that's wonderful. This was a period of four years, you're going back and forth, you're also newly married?

BONACCI: Not yet. I got married--I think, well, it was right before the EIS started, so it was June 25 of 2020, so-- right after I moved from Boston to Atlanta.

Q: All right, so how did you hear about EIS?

BONACCI: That's a great question. I think I vaguely developed an awareness of EIS some time in college actually. I don't specifically remember the moment when I learned about it, but at some point, in college, I was--as I was becoming more interested in global health and medicine, I was just curious to learn more about 00:36:00CDC, and I think at some point, had come across a list of different fellowships or training programs that--or training opportunities that CDC offered across time. There were programs for undergraduate students or for medical students or residents or fellows and so at that point, I learned about EIS. I hadn't known anybody who did it at the time, but I thought, this sounds like a pretty cool program. It sounds pretty interesting, I'll have to file this away in the back of my mind for the future potentially when I'd be eligible for it, not knowing what the next steps of my training path would hold.

As I got into medical school and my interest in infectious diseases and health equity continued and public health and doing a Master of Public Health, I solidified that I wanted to work at the intersections of medicine and public health and so EIS was--continued to be present in my mind. Certainly, a number of Johns Hopkins alumni from the school of public health have gone on to do EIS and so as I came into residency, I thought of it as a potential post-residency 00:37:00training or specialty opportunity. Again, my wife beat me to Boston by year and then similarly, we ended up out of sync for residency and so she finished her residency training in Boston a year earlier than I did and she matched. She went on to train in pulmonary and critical care medicine here at Emory University, so she moved to Atlanta a year before I did and so it worked out really conveniently as it was coming time for my last year of residency and thinking about my next steps. EIS was a really easy and logical fit both from my career interest perspective and also from a geographic perspective because I knew I wanted to move to Atlanta to be in the same city as her. Since we had lived in the same places but also intermittently lived in different places, we were coming to the point in our lives where we knew we wanted to be in the same place in the longer term and so EIS was convenient both from a life and a career perspective, and I was really excited.

I wasn't sure back when I learned about it in college and was thinking about it in medical school, I didn't know if--when it came time to finish residency 00:38:00whether EIS, the opportunity to apply would line up with where I was in my life. I was really excited in residency when the stars aligned in such a way that it was going to be a feasible option to apply for. I applied in, I guess, it was the fall of 2019 and then found out in either early October or so that I got into the EIS program for the subsequent July 2020 start. And yeah, that's where that journey began.

Q: Yes, you're Boston and you're going back and forth to Malawi and Lesotho. When did you first start hearing about COVID?

BONACCI: Yes, so in my last year of residency, I was, as you said, back and 00:39:00forth between my clinical rotations in Boston and then primarily at this point, most of my work was in Lesotho and so it was primarily back and forth from there. I had gotten an early inkling. In the news, there were those early reports of a vaguely understood pneumonia that was happening in Wuhan, China, and I was following it from the periphery thinking like--I think people were concerned from the previous SARS [severe acute respiratory syndrome] experiences like, oh, will this be something like the prior SARS outbreak and-- But I don't think that raised many alarm bells at the time.

I ended up going to Lesotho, I think it was probably in January, so I was there in of part January through the entire month of February, and it was as I started to travel. I remember being in the JFK [John F. Kennedy International] Airport in New York City on my way down to Lesotho in January, and that was the first time I had seen some of the some of the flights that were coming into JFK from Asian countries. Some of the individuals that were getting off those planes as I 00:40:00was waiting for my flight to board for Lesotho were wearing masks, not everybody uniformly, but it was something I noted.

I think culturally in general, perhaps it was more common in some of those countries than it is here in the United States, but it was uncommon for me in a US airport to see people wearing masks. That was the very first bit I remember thinking about it. I returned right at the end of February, beginning of March 2020 and got back into the country just in time before a lot of the international flights started shutting down and before COVID really started to take hold. I remember being in Boston in the early weeks. As internal medicine residents, as it was becoming apparent that COVID had reached the United States in--I can't remember if the first case was in late January or early February, I think our antennas and our awareness was certainly heightened. Because if patients were going to be hospitalized, it was going to be residents and physicians like myself in internal medicine and infectious diseases, critical 00:41:00care specialists, people in the emergency room, or emergency medicine physicians, it was going to be those folks and my colleagues and myself who were going to be taking care of these patients.

I remember in Boston, the first real inkling that COVID was here-- was Biogen had held a conference in Boston. I can't remember exactly what I was doing that day, but I remember reading breaking news reports that the first case was diagnosed at the conference, and suddenly, we were also hearing chatter on our residency text threads and through colleagues at the hospital and our leadership that many of these patients were coming to our health system, Mass General Brigham to--they were going to facilitate the testing for many of these conference attendees. Dozens and dozens of attendees were going to be coming both to my hospital, Brigham and Women's Hospital and our partner hospital, Massachusetts General Hospital for testing. That was the first moment of realization like, oh, it's here. Well, certainly, we didn't know what was in 00:42:00store for us at the time, but I remember that day them--and by them, I mean our hospital administration and our emergency room staff setting up an outdoor testing site outside of the emergency room ambulance bay as one of the first places that they were doing COVID testing for these individuals who had known close contact with a case or a person who had COVID, and that was sort of the moment where things took off.

In hindsight, I think there have been some studies done of that conference that have linked that conference to the spread of COVID to thousands or I think even hundreds of thousands of cases subsequently. It was something we didn't appreciate until hindsight, but yeah, I really distinctly remember that being the first moment why I thought, oh, wow, it's here, and I don't think we knew exactly what the first wave was going to look like at that moment. But certainly, we were preparing in the hospital from that point onward for what 00:43:00caring for patients with COVID was going to look like. I remember our residency leadership was--along with hospital leadership--was standing up these special hospital teams called our special pathogen units--special pathogen units. Those were internal medicine trainees like myself and then senior internal medicine physicians who were going to be taking care of patients who need to be hospitalized for COVID. Certainly, early on, we were a bit more conservative before the actual surge had overwhelmed our capacity. We were hospitalizing many people even if they weren't very ill because we weren't sure what was going to happen to them. Obviously as first surge happened, Boston was probably just behind New York in terms of the burden of COVID early on in the pandemic, and our hospitals were overwhelmed, and that itself was a really interesting experience to be a part of.

Q: Yes. Were you experiencing what everybody else was hearing, that your PPE 00:44:00[personal protective equipment] was running low, were there not enough vents [mechanical ventilators], were there not enough supplies, was there-- obviously, nobody knew really what this was yet, so there was fear in patients.

BONACCI: Yes, absolutely. In those very first days, for example, when we first found out about the Biogen conference cases, I don't think we were too worried in those--literally those initial days about things like PPE. But it quickly became apparent as we started running through it very quickly on our hospital services and hearing stories about other places in New York and in other hospitals in Boston and across country experiencing similar issues that this going to be a real problem. I remember pretty quickly on, our hospital administration was taking steps to limit the use of PPE, both in terms of limiting the access to it, so making sure only people that really needed it or needed particular types of PPE like N95 [respirator] masks were--had access to those.

Similarly, we were extending our use of all of the PPE far beyond what we would normally use. It's painful to think about now in hindsight, but we used to--before COVID in residency, if we were going into a patient's room where we needed to wear an N95 mask, so for example somebody who is on TB contact precautions or was a suspected case of tuberculosis, you would walk into the room, you'd put on your N95 before walking in, you'd do it, and whether that was examining the patient, talking to the patient, whatever it was you were going into the room to do and then you'd come out, and you'd throw the N95 way. It was like you used the N95 once in the room, and you'd get rid of it.

To think about that now, it's quite painful because if only we knew what resources we--it wasn't squandering the resource at the time because it wasn't scarce. But as soon as these cases overwhelmed us in the hospital, I mean we were wearing N95s until you couldn't wear it any longer. For the month of April 00:46:00of 2020, I spent a lot of time working at our community hospital, the Brigham and Women's Faulkner Hospital in an ICU [intensive care unit] that was stood up essentially to take care of COVID patients. I was working in a medical intensive care unit, but it was effectively a COVID ICU. I remember I would store my N95 in a brown paper bag with my name on it, and it'd go up on a shelf that somebody had put up temporarily. All of our nurses, all of our support staff, the care associates, the respiratory therapists, the other physicians, we all had a bag with our PPE. One little bag had our mask and then the other bag had our face shield, and we'd would use those until we couldn't use them anymore, and then we would go to wherever they were dispensing the N95s in the hospital to go get a new one. Certainly, things like gowns, the protective gowns or reusable gowns were more scarce. I remember the antibacterial or disinfecting wipes suddenly became really difficult to find, and yes, that was a very strange experience 00:47:00early on in Boston.

Our hospital system was actually one of the first sites to receive--Battelle I think had created an N95 disinfecting machine or industrial process. There were only a few machines distributed early on to different parts of the country, and our hospital system was one of the first to receive those. The machine was intended for use to serve all of the hospitals in our region, but, yeah, I remember at one point, we were turning in our N95 masks into these bins at the end of the day or after a certain amount of time and then eventually, you would get them back. Presumably they had been disinfected in that time and there was--people were concerned, well, are they as protective after being disinfected or how long can you use them before it's no longer safe to use them. Certainly, early on in addition to the shortages of PPE, I think there was both fear of what equipment was required to adequately protect ourselves as healthcare 00:48:00workers and then also more generally, I think there was the fear of an unknown, rapidly spreading global pandemic that the only glimpses we had of previously were the experiences in China and in Italy and other countries that had experienced some waves of COVID before us. I think there was certainly, both among patients, patients' families, clinicians, and other staff in the hospital, a lot of fear of the unknown. That was sort of the first time--oh, well, I guess I would say that was probably the first time in my medical training that I'd experienced it to that degree.

I had, for a long time, worked with patients who have tuberculosis, which is a disease that's transmitted by airborne transmission. We routinely wear N95 masks when caring for patients with tuberculosis. Since I had focused a lot of my efforts and time on that, I was relatively comfortable or more experienced in 00:49:00being in rooms with patients who had airborne-transmitted illnesses. But that said certainly, I was worried about my own health. I know so, my wife was--she is a pulmonary and critical care fellow here at Emory, and she was working in the medical intensive care units in Atlanta at Emory University Hospitals, and those all again also rapidly became COVID ICUs. Often in my head, I was thinking about her health and safety as she was facing similar PPE shortages and taking care of COVID patients constantly through her training, so I think we both shared some of that fear. It was interesting and maybe challenging for us that we weren't able to be together because we were in separate cities training and both of our hospitals and many training programs and hospitals across the country, as soon as COVID started spreading, restricted our ability to travel because they needed clinical staff. They couldn't have us going on vacation 00:50:00because the hospitals were experiencing surges, and it was an all-hands-on-deck situation.

I saw my wife when I came back from Lesotho at the end of February, I came down--I routed my flight back through Atlanta to visit her, and I went back to Boston. We knew as COVID was getting serious we weren't going to see each other until my training ended in June, and I was making the move down to Atlanta and-- But I think at the same time, for her and I at least, and I would say for many of my other colleagues who share similar interests, there was a fear of the unknown and there was a fear of COVID, and certainly that was very prevalent in patients--among patients and families. But I think we also or at least speaking for myself and speaking for other colleagues who I have talked to about, this is part of why we train to do what we do.

My wife was always interested in taking care of patients who were critically ill, and whether that was critical illness from advanced cancer or from heart 00:51:00failure or from bad pneumonia or from never-before-seen, new global pandemic, we felt like we had spent all of these years training to learn to be clinicians, and this was our chance to answer the call when it was needed. While we certainly--none of us wished for a global pandemic, I think we were also motivated to try to serve in that moment because we had some tangible skills that we could contribute to caring for the patients that were coming in. And even if not--even if the science wasn't to the point where we knew the best ways to care for these patients, if nothing else, we could be there to accompany them in their moment of illness, in their moment of fear of the unknown, of this new disease that they were diagnosed with. Particularly since she was spending time in the intensive care units and I was in a COVID ICU, we were seeing a lot of 00:52:00the most sick patients from COVID. So, I think it was also an opportunity to--unfortunately, many of our patients died and--but it was an opportunity to accompany those patients and individuals in the final moments of their life through what I can only imagine was a terrifying experience for them and their families.

One of the things we hadn't talked about yet but that happened early on in COVID is as soon as there was an awareness that COVID was spreading in the United States, the visitor restrictions in healthcare facilities of all kinds, hospitals, clinics, nursing homes, long-term care facilities all became very, very strict, so families weren't--excuse me--families were no longer permitted in the hospital to visit patients. Previously, families were visiting their loved ones. Often, maybe a son or a daughter would go visit their parent in the 00:53:00nursing home daily or weekly and then for a month, they--or two months, they hadn't been able to see their mom or their dad and then they get a call from a hospital emergency room saying, "Your mom or dad's here with us in the emergency room, they're quite ill, we--they've tested positive for COVID," and that family member isn't able to come in the hospital to go. Not only had they not seen them for a month at their nursing care facility, but now their loved ones are even more sick in the hospital, and now they're needing ICU-level care, and they can't come visit. We are doing our best to take care of the patients and give their body the time it needs to recover, but in many cases, COVID took its toll for many patients, and family members didn't get a chance to come see their loved ones at the end of their life.

I think part of the answering-the-call piece was also just to be present with our patients in those moments at the end of their life. And I don't know, I 00:54:00can't tell you whether I brought them any comfort or not, but certainly, I viewed it as one of my most important responsibilities in the face of an unknown illness that we didn't know what effective treatments were early on. I considered it one of my most important responsibilities was to accompany them in that illness experience and to be there alongside of them, and as best we could, to help their families navigate what was happening as well, which that was really challenging in its own right because again families couldn't visit them. One of the other things that came out of the early days of COVID was we were calling families a lot more. Normally in the ICU, most--for the most part, families are usually pretty present because their loved one is so sick and so we're often having a lot of face-to-face conversations with families, and if they weren't able to make it, we'd be updating them by phone, but really phone 00:55:00and what became video calls were the primary ways we were communicating with families during this time.

It was challenging both because our ICUs were so full, and we had so many patients. The burden of communicating with--it was--there was a higher burden or a higher number of families to communicate with and--but you also had less time to do it because you had more patients you were caring for who were sicker than the usual critically ill patient, so you were spending more of your time focused on the immediate medical care of the patients. One of the side effects was that you had less time to make calls to the families, and also, they weren't there in person. When you're talking to a family about a loved one who's critically ill, those are very difficult conversations, often very emotional conversations for the families and very scary in many ways. You're telling them a lot of really scary things, you're sharing a lot of medical information, and so figuring out ways to do that, ways to address their fears, and to reassure them about the 00:56:00care that their loved ones were receiving, and also helping them to understand how sick their loved ones were was particularly challenging.

We tried to use phone calls, but we started to bring iPads into the intensive care unit, and that was--one strategy we used was basically setting up Zoom calls or video calls with family members because I think in-- one of things that comes up as well is there is these--there becomes an element of distrust or suspicion when again, for example, a family member is doing okay in a nursing home, but you haven't been able to see them for a month or two. Then all of a sudden, you hear that they're extremely sick, they're in the hospital, and then a physician or a nurse from the team calls you and tells you they're so sick that that patient could die in the next hours, days, or weeks. I, again from the perspective of a family member, can imagine that that's terrifying information 00:57:00to hear. On top of that, there's also these complex layers of culture.

We think in the early moments of COVID in Boston, so the communities that the hospital where I was working at served in part are Dominican and Haitian immigrant communities, and we noticed early on in my very local area where the hospital was serving was that many of our COVID patients were disproportionately Dominican patients or Haitian patients or patients from other immigrant communities. It was less so patients from the--I would say, either more White or more well-to-do neighborhoods in Boston or neighborhoods that had a higher average socioeconomic status. I think part of that was because, as you'll probably recall, these widespread mitigation measures or lockdowns or shutdowns, whatever term you prefer for the time, were put into effect. I think in Boston, 00:58:00they were probably in early March. It was easy for people who had white-collar jobs or who worked in an office to transition at work very rapidly to a work-from-home setting. Whereas a lot of the patients we took care or a lot of the patients we were seeing coming in with COVID worked in jobs where you couldn't work from home. They were grocery store checkout clerk, or they were working in the janitorial staff in the hospital, or they were working in the--as a bus driver in the transit system, so things that you had to be in-person to do, putting these individuals at disproportionate risk or exposure to COVID. And then on top of that, so not only were their jobs or their livelihoods putting them at increased exposure, but many of the patients we took care of often lived in multigenerational houses, and multiple generations of their family members lived in the same apartment or home. In addition to having more people in the 00:59:00household and smaller space, they're--there was their increased risk of COVID exposure. They'd go home after work, and inadvertently, COVID would spread in these enclosed spaces because that's one of the ways--as we've learned well, that that's one of the ways COVID spreads well is in enclosed, poorly ventilated spaces. Particularly when in spaces where people don't have room to quarantine or to isolate from each other whether they're exposed or infected, and so.

It was difficult to see so many of our patients coming from our immigrant communities knowing that it had very little to do--it wasn't really their fault, it was circumstances beyond their control, these structural factors that put them at disproportionate risk for COVID. I remember distinctly multiple families who had multiple family members, but particularly one family really sticks in my mind. We were taking care of an adult son in our intensive care unit, and a few 01:00:00rooms down in our same COVID ICU was that person's mother, and they had both been infected in the same home. Then we found out from colleagues who were working at the main hospital, which was just a mile or two away from the community hospital I was working at, that another family member was in the COVID ICU infected with COVID. That really stuck with me because that was the first--again this was in the first wave or the first surge in Boston in early 2020, and that was the first inkling that I had of how COVID could devastate entire families or entire homes and how multiple people in a household could go on to die from this disease. Just to think about how devastating that could be for families and loved ones that you just--yes, that--it's something that still I think about today about how awful that must've been for families who--any family who lost a patient, but particularly families who lost multiple loved 01:01:00ones in rapid succession through spread in the household.

Q: Yeah, the guidance for masking wasn't really clear, but then you have visitor restriction in the hospitals, which helped--not helped, people share their experience but also this had such a high mortality rate before the vaccine was even introduced. We forget that.

BONACCI: Yeah, that--those were definitely some of the most difficult moments of my medical training, both because the intensity of care was higher, the challenges in communicating with families was so much greater when you couldn't do it in person, and because there was all of this fear about this novel global pandemic or this new disease. Then to your point, just the burden of disease, the burden of mortality, the number of patients we saw die was really difficult. 01:02:00Certainly, over the course of the pandemic, there's been far too many deaths, but in those early days, it really often felt overwhelming. Particularly, as you mentioned, we didn't have vaccines. There didn't feel like there was anything that we--we didn't have any well-established treatments at the time. There were some early clinical trials that were getting off the ground in March and April, but we didn't know that remdesivir helped to reduce severe illness or that steroids were particularly effective in those first month or two in the surge in Boston. Medically, people were trying all sorts of things, some of which were things like steroids, but other medical treatments, which ultimately later on, we found out through further testing and clinical study that there weren't necessarily effective. It was very difficult to see the burden of suffering on patients and their families, and to see so many patients die early on was really difficult.

Q: Yes. During this time, testing was one of the things that we did mostly for people who were the sickest, but we didn't know about the asymptomatic portion to this disease. It was just a disease that was brand new, didn't know anything about it, didn't really know the whole transmission route either, so many theories about that. It reminds me of early AIDS [acquired immunodeficiency syndrome] where we didn't really know about transmission route early on, and there was fear, and there was people pointing fingers at certain populations. They have--

BONACCI: Yes.

Q: --but were you doing testing or were you just doing--trying to take care of patients who already had it?

BONACCI: Yes, it was--so my time in the COVID ICU was primarily focused on the clinical care aspect, but certainly testing was always at the top of our minds 01:04:00as clinicians. In the month before, I was working in the COVID ICU in March when COVID was just starting to increase in Boston. I actually wasn't on a clinical rotation at the time. I was supposed to be traveling for some global health work, but that had gotten canceled because of the start of the pandemic and so our hospital system, like many others, started developing emergency procedures to deal with pandemic. And one of those was to create an emergency management structure for COVID. I actually got involved in that month of March when I wasn't on a clinical rotation with the emergency management efforts. Speaking of I guess or related to the testing question you were asking, I got involved with an effort to create a mobile testing unit at an--in our hospital system. As you mentioned, testing early on was a huge challenge for a number of reasons: One, 01:05:00which I think has been well documented in the media now, is that there were some failures on the CDC's side to develop a COVID test early on.

That there was some suspected contamination of tests that were sent out to public health departments across the country, which delayed the development or the availability of testing. That sort of led to very restrictive testing criteria, so only the patients that you had the highest suspicion. Initially, they had to have a known known travel history to Wuhan or to another infected--or affected region or had to have close contact with a known patient that had been diagnosed. To your point, there was a lot of spread as we've learned since that was either happening when patients were asymptomatic or pre-symptomatic and so these really restrictive testing criteria in the beginning meant that we were missing so many cases. I don't know exact--what the exact number was, but I imagine, we were probably only capturing something like ten percent of the cases early on in those first months.

One of the challenges was that testing was also primarily facility based, so you couldn't go--there were no rapid tests in CVS or Walgreens like there are today. You couldn't go to your local pharmacy or corner store to get a test. There weren't testing sites set up all over the Atlanta region at the time or the Boston northeast region at the time. You had to go primarily to major hospital systems to get testing and so if somebody met all of these criteria and needed a test, they had to come to our hospital to get tested. They couldn't go to their doctor's office-- that wasn't available. One of the challenges that that created was for--that's sort of we anticipated and thought would become important was that for people who were homebound or people who lacked access to a vehicle or to transportation but there was suspicion of COVID, those individuals weren't going to have access to testing.

So, I got connected to Scott [A.] Goldberg who's an emergency medicine physician at the hospital where I was doing my residency training, and he had the idea to 01:07:00try and use--so he did a lot of work with emergency medical services in his role as an emergency room physician. He had the idea to use EMS staff and ambulances as a way to deploy mobile testing resources to reach patients who were homebound or who had difficulty accessing testing. I spent some of the early month of March of 2020 helping Scott to try and get through emergency regulatory paperwork approvals. We needed emergency approvals from the state to be able to create this program and to license the ambulances and EMS staff to be able to do this testing and type of clinical care. I think that experience was or that effort was worthwhile and useful, but certainly, one of the challenges of using an ambulance for mobile testing is that you can only test as many patients as you can drive to in the area, and so that's a relatively time-intensive process. But that was one of the ways early on I was involved in--on the testing side of 01:08:00things within our health system and trying to expand the access to testing. Testing was a real challenge, and I know that was something that academic medical centers started to focus on pretty quickly. My hospital, Harvard University, MIT [Massachusetts Institute of Technology], and the Broad Institute really tried to work on developing these large testing platforms where you could test hundreds of samples or thousands of samples at a time. As that slowly improved over time, the availability of testing increased, but yeah, in those early days, I wish--I could only wish we knew how many patients that we were missing in terms of diagnosing with COVID.

Q: We are in--what, around--or in April, so much happens in such little time, I forget that it's just--as soon as it hit in February and March, we had lockdown, 01:09:00everybody went home, you had everybody teleworking. Some people couldn't telework, and, as you said before, most of those people were the ones that were coming to the hospital because they could not telework, and there was no masking guidance that was clear. It was all kind of hard-- hard to know what to do at that time because of the quick actions of this virus and how it was mutating quickly as well. Well, there's also a period of time where you had a health issue too in end of May, but before we get to that, I want to talk about your thoughts at the time as a clinician treating patients. Early on in the first few months, there with this hero culture that came up and surrounded healthcare 01:10:00workers who you saw a lot of people applauding healthcare workers. But we had talked about how that's just what your job was, and you shouldn't be applauded for that. It's really the jobs that need more recognition were the grocers and the store clerks, or it's the janitors that you spoke about earlier. I just want your thoughts on that.

BONACCI: Yes. I think that was one of the things that felt really strange to me initially. Again, as I was saying, I think my wife and myself and other colleagues when we were faced with the opportunities to serve on these special pathogen units or to work in COVID ICUs, I think we jumped at the opportunity, my colleagues jumped at the opportunity because again what a gift it was to have embarked on this training path and to have developed these skills at this time that was so important that these skills were needed. Particularly at a time too 01:11:00when I think many people were feeling really not only afraid but helpless. Like they were told, stay home, don't do this, don't do that, and didn't necessarily feel like there were easy ways to contribute to their communities and to address what was going on. I think some people in their communities came up with really creative solutions like helping neighbors, vulnerable neighbors-- shop for groceries and things like that, but in many cases, many people didn't feel like they could do anything about what was happening around, and there was a real sense of lack of control or loss control.

It was a real gift for myself personally to feel like I had clinical skills and training that was useful during this time, but certainly, one of the strange--I don't know if strange is the right word but just different dynamics that developed early on was I--and this has never happened before in my medical training, but I started getting calls from a lot of friends checking in on me, which I'm grateful for. I appreciate that my friends were thinking about me and 01:12:00how I was doing, but again, checking in, making sure I was doing okay both mentally and physically with the work but also thanking me for the work I was doing. My colleagues and friends were getting similar calls from family. I was getting cards in the mail, people were sending care packages, which again, I was incredibly grateful for and was really appreciative of to have such thoughtful friends and family. But I think you saw this too in places like New York City, you saw YouTube videos, people recording, every evening, people would come out to their balconies, and they would be clapping for the healthcare workers at a certain time in the evening. It was just a little different because it certainly wasn't something that we were used to, and again, I think many of us felt like we were doing the job we were there for and that we had been trained. Now having the full expanse of the pandemic, for this brief period of time, there was this interesting hero culture, and there was a lot of language of healthcare workers 01:13:00are heroes or nurses are our heroes. I think there was a little bit of awareness too of other what we now call essential workers, grocers, people working at the--bank tellers, sanitation workers, other store clerks, postal service workers. I think there was a small recognition of their importance and essential nature to keeping our society functioning as well. But it always felt weird from the perspective of being a clinician that--to receive this overwhelming recognition for it while there were so many other individuals in roles that were as necessary to keeping our society functioning in that really scary time.

The other interesting corollary about that hero culture is just how quickly it diverged or changed-- the climate changed. I think that was particularly prevalent in the first surge in the northeast in Boston and New York City. But 01:14:00as COVID started to crest and come down from that first surge, and again, nobody knew what to expect then and so people thought, well, maybe the pandemic is waning, like maybe we'll get past this, we can get back to regular life. And then, I don't remember, it was specifically late May or early June when cases started--mid-May or early June where cases started rising again. I think that's where--along the way, there had been through the introduction of the politization--politicization of COVID earlier on than that even during the first surge, but I think it really became--took a greater hold throughout that time period. Culturally, I think that's where the divide to me became most apparent was after April, and suddenly, as we were starting to ponder COVID cases rising again, people were recognizing that with an appropriate degree of humility, we don't really know what this pandemic is going to do, we don't know how long it's going to be around with us. Vaccines still weren't around then, they were in the 01:15:00development process, and so we don't know how often we were going to be in and out of lockdowns or other mitigation measures being put in place.]

And there started to be sure this kind of negative undercurrent to some aspects of what you were seeing around COVID and more elements of distrust or disbelief or misinformation being spread around the pandemic. Certainly, I even took care of some patients who were hospitalized for COVID, we diagnosed COVID, but didn't believe they had it. Even though they were sick, they didn't believe they had it, or family members didn't believe that COVID was a real thing or--you know I remember the controversy around counting deaths from COVID-19 on death certificates and whether a death was related to--was a result of COVID or whether it was just that a person had died and had COVID, but COVID had nothing to do with it. There was these insinuations that physicians were doctoring death 01:16:00certificates or mis-recording things or that--there were these ulterior profit motives that we hear other healthcare workers had. Again, it's sort of--things became rapidly politicized and led to this really interesting, harmful culture of distrust and of misinformation, and the reverberations of which, we continue to bear the consequences of today and which, I think, undoubtedly led to many more preventable deaths and preventable suffering and illness for many families across the country.

So, yes, I think the link there to the hero culture piece was that sort of a hero culture was unusual and surged initially, but then very quickly, the political dynamic changed, and I think we've been fighting ever since to figure out how to speak with a shared language. This, I'm making generalizations, 01:17:00mostly hear about the experience in the US, but how to speak with a shared language and shared understanding of what COVID is and what are ways to protect yourself and what's the overall risk of COVID. You know I think our American society has gone through a lot of growing pains in the last two and a half years of the pandemic. Growing pains or splintering, I don't know which is the right term or maybe both, but those are certainly--from the perspective of somebody working in public health and healthcare who cares about the health of my patients and cares about the health of our communities, that's been a really challenging undercurrent and dynamic to the pandemic.

Q: Do you think the misinformation has really had an impact on public health, or is it just surrounding COVID?

BONACCI: I think probably both. I think the distrust, the misinformation I think COVID was the nidus for it. And I think that it's not necessarily unseen, you 01:18:00know in a novel pandemic that's filled with a lot of fear. I think misinformation and misunderstanding, or distrust is part and parcel with a pandemic that has spread as widely and affected as many people as COVID did early on. But certainly, I think the political response at the federal, at the state, at the local levels, I think of the difference is that--from--compared to past pandemics or epidemics is that those elements really fomented the misinformation, particularly at the federal leadership level or the executive leadership level really fomented the distrust and misinformation around the pandemic. I then I think that has more broadly spread from COVID to healthcare, to healthcare systems, and to public health in general and so that distrust, while its nidus or its origins may be in the COVID pandemic, I think have spread more broadly to medical care, to trust or lack thereof in our public health 01:19:00systems, in our hospital systems, in the value of communication coming from clinicians, coming from hospital or healthcare organizations, coming from public health organizations or our public health leadership at state, local--at state levels, the state health departments or local health departments. Certainly, at CDC, I think it has changed in many ways the way these agencies and health departments are perceived and then again, I don't think this is uniform for everyone. I think there's, in some ways, been a splintering in our society of people that you know believe in the value of these organizations and agencies or, even if they don't agree with everything the agencies are doing, and then there's a segment of the population that has been--become very distrustful over time of public health authorities and clinical authorities. I think it's made 01:20:00things fairly challenging or far more challenging than they necessarily needed to be.

Q: Do you think the mistrust stem from leadership at the federal level not having a clear message or CDC not having clear messaging?

BONACCI: Absolutely. I think the pandemic and the failings are so large and widespread, so as not to be laid at the feet of only one person or organization, but certainly I think our failures in communication extended to the highest levels of our federal government. Certainly, we had a president at the time, Donald [J.] Trump, who was often in the COVID briefings at the White House. I remember how ridiculous it was after he was joking about injecting bleach and using Lysol as ways to treat COVID. Certainly others--himself and others in the 01:21:00administration were pushing things like hydroxychloroquine or ivermectin treatments, which have been shown repeatedly now to not be effective in treating COVID. I don't think they're the only ones that bear some blame here. Certainly, some of the principles are important, principles of crisis communication or clear communication, consistent communication, empathic communication. Recognizing what people are feeling during a particular scary time, recognizing, and acknowledging, what we know and what we don't know, and communicating the ways we're working to address those gaps in knowledge. I think that there were a lot of failings on the part of CDC to communicate those things clearly.

I think the experience at the state level had varied widely by state. You had some state health department leaders or commissioners who were particularly 01:22:00adept at crisis communication, and I think you had others who were not nearly as strong and then similarly, that I think you can apply that to the governors of states and, yes, I know. I don't think the failing in communication is laid at the feet of any one person or organization, but certainly, the influence of such misinformation and misdirection and just not very clear public health communication from the very highest levels of the federal government and state governments made addressing the pandemic and getting all of society on the same page or at least having a shared understanding of what was happening and what were the ways to address it, it made it incredibly challenging. And I have no doubt that, it cost a lot of lives, I don't know how many lives it cost over the course of the last two and a half years, but there's no doubt that more people 01:23:00died as a result of our poor national response than were necessary. I think you just have to look at the experience of some of our other peer countries to--and you can compare case levels and COVID mortality and see that in many cases, we're an outlier for a nation of so many resources, financially and economically, to have as--experienced as high of a burden of COVID and COVID mortalities we have.

Q: Yes, you mentioned the states, states also have their own ability-- their rights to healthcare. So, you have the federal guidance, but it's up to the states too--whether to use that guidance or not.

BONACCI: Yes.

Q: All right, yeah, which makes it not so clear when you're going down to the state level from federal.

BONACCI: Yes, absolutely. Aside from the public health crisis communication 01:24:00piece is the legal framework for public health in the United States and our federalist system really imbues the power of public health primarily is left to states and to local jurisdictions. I think that also affected the COVID response. Rather than one unified national response, what we really had was either dozens or hundreds or thousands of different niduses of leadership in addressing COVID. Whether that was different health--state health departments with different policies or whether local health jurisdictions had the authority in their area, you had a variation on response in every place you went. I think that also made coordinating a nationwide response more challenging when thinking about where the public health powers in our country lie. Certainly, I think that was apparent on the data collection side of things where CDC only has so much 01:25:00statutory ability to compel states or jurisdictions to provide data on COVID cases or other health conditions and other reportable diseases, and so. Without having worked directly in those areas, I think the repercussions of that was also apparent early on in that it took a long time for us to get really, really good case information. Part of that again was a testing problem, but some of that also was accounting the number of people who have tested positive problem and then transmitting that number to a central authority. So, yeah, that's another interesting dynamic as well aside from the federal leadership and communication piece.

Q: Yes. I hope we have these lessons learned. In May, you have appendicitis, how did that happen? You were in the middle of the ICU, and you just all of a sudden 01:26:00realized, hmm, something's not, right?

BONACCI: Yes. April of 2020, I was in the COVID intensive care unit at the Faulkner Hospital and then--so May, I was actually in the--I was back at our main hospital, Brigham and Women's Hospital in one of the special pathogen units, so I was taking care of COVID patients, but patients who weren't quite as ill and needing ICU-level care. At one point, I had had a weekend off and so with a couple of other friends who were working in the COVID unit, since we were all exposed to the same patients, we had basically rented a house down by a little river in the Poconos. We were going to go as a kind of a place to decompress for a couple days, and it was while I was there. I don't even think I'd been there a day and started to develop worsening abdominal pain. And we were all physicians, and we were joking early on, as it was like getting a little bit--we're like, oh yeah, it sounds like appendicitis, but what are the chances? We all assumed it was unlikely, and it continued to get worse and worse, so much so that I woke my friend up about an hour after going to sleep in 01:27:00the middle of the night. We were about a five-and-a-half-hour drive from Boston, and I asked him if he--because I had driven down with him, and I asked if he'd drive me back because I was in so much pain. Literally, we drove in the middle of the night through darkness to get back to the hospital where we trained in Boston. He drove me straight to the emergency room, and I was diagnosed with appendicitis and--a ruptured appendix rather and--it was strange to be on the other side of the equation. I had spent the last two months taking care of COVID patients there and for the last four years taking care of patients in that hospital. To be a patient at the end of my residency experience in the last month or so of my residency experience was certainly interesting.

I was talking about the visitor restrictions earlier and the impact that that had on families, and it was, I guess, funny for me, it's perhaps--certainly, it wasn't funny for other families. But when I called my wife as we were getting close to Boston to let her know I was going to the emergency room, I didn't want to wake her up while she was sleeping, and I had a five-and-a-half-hour drive in 01:28:00front of me. As I was getting ready to walk into the emergency room, I woke her up, it's like, I don't know, about seven o'clock in Atlanta, and told her I was going to the ED [emergency department], and I thought I had appendicitis, and I was going to ask them to do a CAT [computerized axial tomography] scan. I subsequently got the CAT scan, within a couple of hours, I had a diagnosis. She was on a plane a few hours later to come up. She couldn't come visit me in the hospital and so she flew all the way there only to have to stay at my apartment. And I remember at one point, she drove to the hospital but parked out on the street, and I knew what street, I could see her from my hospital room window, and I flashed the blinds so that way she could figure out where I was, which room was mine, and that was how we saw each other--that was the first time we'd seen each other in three months or maybe like two and a half or three months.

But I was lucky in that many of my friends were residents at the hospital and so even though technically, I couldn't have any visitors, I had a lot of workers who were--a lot of clinicians--who were coming to visit me and so that was a real comfort. But certainly, it was a bit ironic to have that experience at the 01:29:00end of the residency. I will also say it was, in some ways, very gratifying to receive what I felt like was really excellent care from the hospital staff, and to know that I had trained in a place that takes good care of patients was reassuring after four long years there. But, yeah, that was not a fun way to end residency. I wouldn't recommend appendicitis or ruptured appendix to anyone, so it doesn't happen at a fun time anytime. But it was, I suppose, the one silver lining was that I got see my wife when I got home after a few days in the hospital, and she was able to stay for another day or two to help take care of me and make sure everything at least was okay before she headed back to Atlanta to continue working in the COVID ICUs down there.

Q: Did you go right back to work the next week?

BONACCI: No, no, I couldn't--I actually couldn't go back to work for little while because of lifting restrictions, activity restrictions after the surgery. Eventually, I wasn't on any clinical service for the month of June and so I 01:30:00spent that time slowly packing up my Boston apartment and then making the move to Atlanta before I started EIS.

Q: When you were in the hospital with your appendicitis, were there other COVID patients around you or were you in another wing of sorts?

BONACCI: In the specific part of the floor, I was on, I don't think there were any COVID patients because I was in a surgical unit, but I suppose on other parts of the floor, there were. They tested me, at this point, testing capacity was a little better towards the end of May and so even though I had no respiratory symptoms of any sort, and it was--they had a diagnosis on my CAT scan, I--they--I got a COVID swab, and they had to test me before going in the operating room. Because if I had had COVID, then the surgeons would have had to wear N95s during the case and--but, yes, I wasn't specifically hospitalized in a COVID unit at the time.

Q: Okay, all right, so now you're packing to go to Atlanta, let's turn towards EIS. You got pre-matched over the phone in the fall and you--so you knew you 01:31:00were going to HIV, correct?

BONACCI: Yeah, exactly. I finally got into EIS in early October. Pre-match happened in November, and I saw that one of the programs or one of the sites participating the pre-match was the--at the time, it was the epidemiology branch, now the HIV research branch, in the Division of HIV Prevention. I knew I was potentially interested in HIV positions and so I had applied to pre-match to that site and interviewed with Dawn Smith, my now supervisor, and Mary Tanner, my secondary supervisor and was fortunate enough to get the position then. Which in hindsight, so you know COVID wasn't around at that time and so there wasn't any other motive other than I was really interested in continuing to do HIV work in EIS. But it was a silver lining because as I spent the month of April in the COVID ICU working long hours most of the days of the week, six days a week. EIS 01:32:00conference got canceled in 2020 because of COVID and so for the first time ever, they were doing virtual recruitment. Normally, the EIS officers are undergoing their match experience at conference, but instead, there was a virtual match experience for all the rest of my colleagues, and that was happening over--I think it was a six-week period in April and early May in 2020. They were having to have phone calls and Zoom calls with different positions and meet different supervisors and then you rank the ones wanted to interview with and then you ranked--or so you listed the ones you wanted to interview with then you rank the ones that you did interview with and ultimately you get matched up at the end. But I was fortunate that I had already pre-matched because, I don't know, doing the clinical work I was doing at the time, I would have barely been able to make all of those calls, so it was a blessing in disguise I guess you could say.

Q: Yeah. You mentioned the conference, which is--usually it happens in end of 01:33:00April, early May?

BONACCI: Yes.

Q: Yeah, and you go around, and you interview with people who have positions open, and you'd see how you get matched and--but you didn't have that. Your orientation was entirely virtual, and you just came into somewhere? Did you come into the main campus and pick up something, your badge, and your computer and then you went back to an apartment, and that's how you started your EIS two-year?

BONACCI: Yes, it was certainly an interesting start to EIS, a very, I would say, unusual and nontraditional EIS experience, yes. Normally, EIS officers have a summer course, I think it's in-person at Emory University or the main campus, but for us, it was all virtual. They flew all of our state-based officers or jurisdictional officers into Atlanta because everybody needed to get their ID [identification] badges and their laptops, but none of the coursework was actually in-person. So, all of our state officers who had traveled in were all 01:34:00in hotel rooms streaming it virtually, and I was at my house doing this virtually. Other than going to campus, I think I went to the main campus just once to get my--I did my occupational health appointments and picked up my computer there and then had to go to Corporate Square to take care of some ID stuff. Other than that, I wasn't in the office really at all, not just for the orientation but you know for the coming months and years, so that was certainly a strange experience.

I general, I think one of the big draws to EIS is the network of EIS co-fellows that you're with and then the other colleagues that you meet, your supervisors and other people that you meet on responses, and in the agency in general, and that I think has been the most difficult thing for EIS officers in my class, the class of 2020. Somewhat for the class of 2019, although they had a year of 01:35:00normal experience before, or at least part of a year normal experience before things turned upside down, and then certainly the class of '21 is experiencing similar challenges.

But we were the first class that entered CDC in a telework-only or remote-work-only environment, and at the time, vaccines also weren't available when we first started and so there was still a lot of caution around socializing and social events because I don't think anybody, rightfully, didn't feel particularly protected from COVID at the time. It wasn't later until December of 2020 that the first vaccines were rolling out more generally to healthcare workers and then early January or maybe early February here in Georgia, at least, to people working in public health and to first responders and so-- yeah, one of the challenges the last couple years of EIS is--for our class has been how do we build those connections and build those friendships that I think are so central to the fellowship experience. For many of us, it was the biggest draw 01:36:00or the reason that we--or one of the biggest draws or the reason that we decided to do this training program.

Q: Yeah, that is one of the biggest things about that EIS is that class bonding and the fact that you create these bonds and then you got back out into the world and have this network of colleagues that you can depend on for certain things. It's sad to see that you didn't have that, but I'm sure there were other things that you guys figured out because EIS officers are quite capable.

BONACCI: Yeah. We tried to come up with creative ways to socialize and spend time with each other and understanding that some people would feel a little more safe with certain things and others might be a little more cautious and would bow out, and everybody would be understanding of that. For example, during the summer course, again, all of the state officers had actually traveled into Atlanta. This is one of the few times in our two years we were actually all going to be together in the same place and so even though the program itself 01:37:00wasn't organizing any of the coursework or any social events in-person from a program perspective, we did take it on ourselves as officers to try to do some outdoor socialization. I remember one of the things was we all met up in Decatur Square, and there's a picture of everybody sitting on the grass at six feet apart, and people were wearing masks. Again, this was before we had a great understanding that transmission was much more uncommon outdoors and--but we tried to come up with creative outdoor, COVID-safe activities like that as a way to get to know each other a little better. And even after summer course ended and our state officers returned to their sites, it was challenging to socialize, but officers tried to find a way to do it safely, going on hikes with each other. Certainly, once vaccines became more widely available, people at least 01:38:00became a little bit more comfortable with spending time in close proximity with each other, even still, many of the social events were often outdoors early on. There were more surges that happened over time and--

I think one of my favorite things about two years in now and at the tail end of EIS is, you know, the opportunity to have met such wonderful colleagues and co-fellows. While I feel like and while I think many of my colleagues feel like we did miss out on some of that building a bond, we tried to find other ways, again outdoor events. We created virtual happy hours where people would get on Zoom calls all together and just try to find other ways to connect. Because I think there's this really cool group of people who are really kind, really motivated, really interesting people from all walks of life and with lots of different academic backgrounds but share this similar interest in public health 01:39:00and epidemiology. And the fact that we also have this shared experience of having gone through EIS at a very strange time altogether, I think, was motivating for us to try to build those relationships and those bonds that we had heard all about. Yes, I think, in some ways, COVID took a lot from us, and at the same time, it also has forged a unique bond among EIS officers in the class of 2020 as the first completely, COVID, pandemic class, and so I am grateful to my now friends and co-officers and co-fellows for, getting to know them. They certainly help keep me motivated to do the work that we're doing, and I look forward to--one of the things I'm excited about as we're graduating from the fellowship, and people are moving on to different steps in their career--is to knowing that I have this network of friends around the country who will continue to work in public health in the coming decades and are people that I'll 01:40:00be able to call on for advice and for help and hopefully will get more opportunities to work alongside of.

Q: So that is part of the whole EIS program is to create that network, so I guess it was successful even though it was unusual. Can you do me one favor? When you're talking about state officers, can you explain what those are or who those are?

BONACCI: Yes, absolutely. The EIS program has a couple of groups of officers. We have officers who are based at CDC locations, the majority of whom, as you know, are here in Atlanta where the majority of the CDC campuses are, but there some individuals in Cincinnati at NIOSH [National Institute for Occupational Safety & Health], there are some--I think it's Fort Collins, Colorado, at the CDC site there. But then there also officers who were out in state or local jurisdictions, so places like the New York City Department of Health or the Washington State Department of Health or I think there's officers in Texas and in New Jersey, Florida, elsewhere. When I was referring to the state officers, I'm referring to the EIS officers who are based outside of a non-CDC location in 01:41:00a jurisdiction instead.

Q: So, they're assigned to states departments of health?

BONACCI: Yes, either state local or in some cases, tribal departments of health, yes, exactly.

Q: Okay. Okay because we're--there's Indian Health Services which is part of this web of HHS [United States Department of Health and Human Services].

BONACCI: Yeah, yeah. Yes, and I don't know if we specifically have anybody at an IHS [Indian Health Service] site, but I do know some of the--there are some sites that even if they're not a part of IHS, have the opportunity to work directly with tribal jurisdictions and organizations.

Q: Yes. Okay, and so let's move to some of the things that you were working on during your EIS time. I think there was one in Washington?

BONACCI: Yes, so that was my first, so that was right after summer course ended in late August. I deployed to the State of Washington with my co-fellow who is 01:42:00based at the state, Jay [James S.] Miller. We were going out there as part of a larger effort by CDC to understand contact tracing for COVID and how it was working in the United States and the diversity of--excuse me--contact tracing experiences that health departments were seeing. One of the things early on so when COVID first surged, contact tracing was one of the primary measures for controlling the spread of COVID. This again was before we knew about any treatments, before vaccines were available, and so health departments really turned over their workforce and really focused, especially as the first surge happened, on contact tracing to reduce the spread of COVID. But health departments were so overwhelmed by the pandemic that nobody had really had an opportunity to step back and say, is contact tracing working, how are we doing from a process measure perspective, are we reaching community members, are we identifying contacts, are we reaching them in time for it to be useful?

So, some of the folks in COVID emergency response at CDC, Patrick [K.] Moonan and John [E.] Oeltmann among other folks that were working on contact tracing, had this idea to try to use--to have EIS officers go to various jurisdictions who were interested in having their COVID-19 case investigation and contact tracing systems evaluated. Jay solicited interest from the Washington State Department of Health, and they specifically asked us to go to Chelan and Douglas Counties, which are in Central Washington. Again, we were going at the end of summer, and this was following a surge in COVID cases in Central Washington in that area, in particularly there was a high case burden in that summer in the migrant farmworker population. So that area of Washington is primarily an agricultural economy, and there a lot of migrant farmworkers who travel there seasonally to work, and summer is one of the seasons that they're there and so there was a high rate or high incidence of COVID at that time. And so the local 01:44:00health department and the state health department were interested in understanding more about how the contact tracing system was working, and particularly in that unique population, the migrant farmworker population, I think part of the suspicion or part of the reason the local health department was interested was because they suspected COVID was spreading, in part, related to concerns in the migrant farmworker community about interacting with case investigators or contact tracers. Certainly, I think migrant farmworkers have unique immigration-related concerns that others may not have and so we had the opportunity to go out and do some work in that local area and to understand more about the contact tracing systems. What I think was unique about what we found or--and this was echoed subsequently at other sites that were also evaluating contact tracing in different jurisdictions was that, in some ways, contact tracing was working well.

Case investigators were reaching the cases to--by phone, and they were reaching contacts relatively quickly once they had their names and their contact information, but what we found was that cases were not naming close contacts. I think something close to seventy percent of individuals that were cases with COVID didn't name a single close contact, and if you just think about what the average household size is and even under lockdown conditions or under some of the early mitigation measures being used, it would be pretty unusual for that many people to not have at least one close contact if not many. So, while the work we did doesn't definitively prove that people weren't disclosing contacts, I think there was a suspicion that one of the areas where contact tracing was breaking down was in lack of disclosure of close contacts. And again, contact tracing and its effectiveness is predicated on reaching exposed individuals early before they become potential cases or develop disease and having them 01:46:00quarantines so that they don't propagate the onward spread of COVID.

I think it's the other interesting corollary to our finding again, I'd mentioned that the local health jurisdiction was wondering about whether particularly the migrant farmworker or Hispanic Latino population there was not reporting contacts at a higher rate, maybe because of immigration-related concerns. But what we found was that when looking by race and ethnicity, there really wasn't any difference in the rate of disclosing contacts, close contacts whether White individuals--so the area was primarily--racial, ethnic makeup was primarily White and then there was the migrant farmworker community, so whether those populations or communities had similar reasons for disclosing contacts we're not sure or rather if were not disclosing contacts, but in either case, it seemed like they were--there were high rates among both communities.

Another area that we also realized that that was challenging was that there were 01:47:00a lot of data systems sort of patched together early on in COVID and so an initial case would--or a test result would get produced by the lab, that would get sent somewhere to the state health department, and it would reside in one database. But then all of the positive cases would need to get sent to another database related to case investigation and contact tracing so that way, the case investigators have the information of the patients to call. There were these multiple databases that were being layered on top of each other, and it was taking a long time for the data to travel in between those to finally get to the people who needed to make the calls. So that was another important delay I think that we learned about. Once the case investigators got the information and it was in their queue, they were pretty effective in terms of reaching people and doing so quickly. But once you piece together all these delays in the process, I think the other thing that that we found, it's specifically in Washington but also that was found as part of this larger evaluation nationally of contact 01:48:00tracing, was that, in general, contact tracing wasn't happening fast enough to perhaps function optimally in terms of reducing the onward spread of transmission. Which isn't to say that it didn't reduce it at all, but that there certainly were ways that it could have been improved to reach close contacts to--basically to help facilitate them quarantining sooner.

I think there are-- there other elements to that, not related to our work specifically, but you know isolation and quarantine early on were quite burdensome, often ten or fourteen days. For people who don't have stable employment or who couldn't miss fourteen days of work and might lose their job or didn't have anybody else who would be able to go out and do grocery shopping for them or provide some of the essentials resources they need at home to quarantine or isolate safely.,I think there are other dynamics there we don't 01:49:00necessarily in many places in the country have a very strong social safety net or a strong community fabric of support for situations like this. I think that was another unfortunate challenge of the pandemic was how do we mobilize support to help make isolation and quarantine more feasible or more possible for many individuals. Some also don't even have--don't have space in their apartment or their home to safely quarantine or isolate from other family members, which again, that was something I was seeing before EIS in many of the patients living in multigenerational homes that I was taking care of.

Q: Right. When people would test positive or were in close contact, they were meant to quarantine, this is part of our--how we handled this. Quarantine time had a tendency to change too usually it was fourteen days or it's twenty-one days or--and it changed over time to I think it's now down to five days.

BONACCI: Yes.

Q: But people had to isolate themselves from their families for a period of time, and as you said, not many people have that opportunity to do that. Even when you were somewhere else like if you were coming back from another country, they would ask you to quarantine in a--where, a hotel?

BONACCI: I wasn't involved as much in sort of the returning traveler side, but yes, I think hotels initially, some of the individuals who were on cruises very early in the pandemic were quarantining at military quarantine stations, things like that, yes. One of the things that that again I saw early on, on the patient's side is the clinicians working in the hospitals but also was also echoed in some of this work in contact tracing was--and certainly that we saw in the case numbers and the death numbers early on was that COVID really made I think blatantly obvious for many who don't necessarily do work on the social 01:51:00determinants of health or think about the impact of racism or think about health equity and social injustice in their daily work. I think it made it really obvious that populations and communities, particularly communities who were being disproportionately affected, and so again, we saw high COVID rates in the Black community or in the Hispanic/Latino community early on and the high mortality rates in those communities. It's all interrelated. It's related to the likelihood that these individuals are essential workers who can't work remotely. It's related to their ability to quarantine safely whether they live in multigenerational homes that are--where they don't have a safe space to quarantine, and it's related to their underlying health status. Again, this was just one more iteration or realization of the--or one of the--one more manifestation of decades of health inequities. Just COVID just sort of laid 01:52:00those to bare in ways and in numbers that were impossible for society to ignore anymore.

Q: You are talking about the migrant population, and that was a high COVID burden during that summer, but the political climate at the time also made this community a little uncomfortable if you would--during contact tracing, which is why they would not, or maybe not name close contacts, or just very distrustful of government at the time.

BONACCI: Yes, absolutely. You had a presidential administration at the time that was doing everything in their power to further restrict migration into the country, was reducing the number of refugees that were able to enter the country, the number of legal immigrants that could enter. Certainly, there was increasing emphasis on immigrations and customs, ICE [US Immigration and Customs Enforcement] increasing enforcement internally within the country to expel 01:53:00immigrants from the country. I think even before COVID happened, I think the Trump administration undoubtedly created an environment of fear and distrust of government among migrant communities, particularly Mexican immigrant, and Hispanic/Latino immigrant communities. When it came to things like contact tracing, I don't think most people distinguish between one government agency versus another. That distrust for government runs across. Again, it doesn't distinguish between activities, and I think certainly--and for this community may have made contact tracing harder for that population even though we saw that other populations were not disclosing contacts at a similar rate.

Q: Yes-- after this deployment, where did you go next?

BONACCI: I spent some time back in my division, but then my next COVID-related 01:54:00deployment came later on in March of the next year, so March of 2021 to May of--through May of 2021. I was deployed remotely in the Emergency Operations Center [EOC] to our post-COVID conditions unit so that was, at the time, part of the Health Systems and Worker Safety Task Force. This was, pretty early on, one of the first efforts by CDC that the--this unit had been stood up a few months beforehand but was one of the early efforts by the federal government to start to understand a bit more about the long-term health effects of COVID, and I think colloquially what a lot of people call long COVID. We were working remotely here out of Atlanta, I was working with a group of other EIS officers and then some other epidemiologists and staff, some former EIS officers who were leading the unit here in Atlanta. Our job really was to understand more and to help try to organize CDC's efforts to understand more about the long-term health 01:55:00effects of COVID.

One of the projects that we worked on that I think was most impactful at that point in time was to develop some interim guidance for clinicians for the diagnosis and management of what we were calling post-COVID conditions, again what I think you were seeing in the media known as long COVID. That was a really interesting effort to be a part of for a few reasons-- One, there was so little known about long COVID at the time or post-COVID conditions. I think what was known in the first month afterwards, people were initially getting infected in March and April in New York, in Boston, and in the Northeast and then slowly trickling out in places like social media were that some of these patients weren't--that they may not have COVID any longer in the sense that they weren't testing positive anymore, but they also hadn't returned to their usual state of health. People were experiencing things like brain fog, changes in smell and taste, increased fatigue, among a host of other things, skin changes, really 01:56:00reporting symptoms across to the spectrum of organ systems. As we got further and further out from the very initial introduction of COVID into the US, we started to realize it could last longer and longer and longer and so these reports initially on social media started--patients started to find each other and created advocacy organizations and places of mutual support.

That's when CDC and the federal government started to recognize that it was important for us to start to do a little bit more work to understand these conditions, to try and study the epidemiology of them, and then also to try and provide some instruction or some guidance for clinicians across the country to diagnose and manage these [symptoms] and what they [patients] were [experiencing]. And I will say that was a particular challenge because we were doing this in the face of really limited information, but I do think it was an 01:57:00important effort. This guidance was developed internally by clinicians at the CDC. We consulted with some of the other staff who had previously worked on other responses and had developed for example interim clinical guidance for the EVALI [e-cigarette, or vaping, product use associated lung injury] during that response. We consulted with clinical experts from different specialties across the country, we consulted with patient advocacy organizations, with medical professional organizations such as the American College of Physicians, and ultimately produced this guidance, which provided some background about what post-COVID conditions were and the range of possible clinical presentations and then also provided some information about how to manage those things.

I think where we're still at, mostly with post-COVID conditions and where we certainly were at then, was that it's primarily symptomatic management, meaning that there was no disease-specific therapy for patients at the time. And it 01:58:00really was managing their various symptoms in the best ways we knew how, so whether that was headaches or brain fog or difficulty breathing or persistent cough, some of the other things I had mentioned before--it was directing treatments towards those specific symptoms. But what I think was really important about the effort and what made that effort to develop the interim clinical guidance so worthwhile was that a lot of the guidance document focused on the importance that clinicians empathize with patients and their illness and their suffering.

Not only do they empathize with it, but that they recognize it and give it a name and acknowledge it, which for the patients who have been experiencing the long-term effects of COVID, some of whom only have these effects for a few months and some of whom have had them now for multiple years, I think it was really important that the federal agency charged with protecting the public's 01:59:00health put this public document out that recognized that there is this set of conditions we don't necessarily know much about yet, but it's important that clinicians recognize them, that they offer support to their patients longitudinally, that they accompany them through this illness process, that they--I think another important aspect of the document was that what a lot of patients early on were communicating to us particularly through these advocacy organizations and these patient organizations was that they were often dismissed by their healthcare providers or by the clinicians they were seeing. When they'd say, "I'm having these symptoms many months out," many of them felt dismissed by clinicians. They were either told that "Oh, we'll continue to monitor the symptoms, but there's nothing we can do about them right now," or often, they were told that they have depression or anxiety, and that that's the root of these symptoms.

That would be understandable if they had depression or anxiety because we're living in these really scary times, and that can cause a lot of stress and 02:00:00adverse responses. While it may be true that some of the patients were experiencing symptoms related to mental health conditions such as depression or anxiety, I think we encouraged, the document really encouraged clinicians to not solely attribute the origin of these symptoms to that, particularly without exploring other medical causes or possibilities first. I think that was another really--was another important aspect of the work, and that touches on a larger history about post-infectious complications or post-infectious illnesses that are of long-term duration. There are other conditions like myalgic encephalitis or there some individuals who develop Lyme disease and then develop long-term effects afterwards, and admittedly, some of these things are not necessarily well understood. Certainly, the science of post-COVID conditions or long COVID at the time was very poorly understood, and even now, the understanding is only 02:01:00growing slowly. So, I think it was important that, again, a federal government agency was recognizing that there is this group of patients out there, that their illness experience is real, it's valid, it deserves medical attention and support, and also that it is not necessarily due only to mental--to anxiety or depression or other mental health conditions. That instead, it may have another sort of medical origin, and that it's incumbent upon clinicians to be thoughtful about that and to create a diagnostic and treatment plan that meets the patients where they're at and tries to work through this over time with them.

That was something important from a patient advocacy perspective and so, yes, that was--I think, too, it's difficult from the clinician's side of things when 02:02:00you're faced with a patient who has a set of symptoms that you can't necessarily explain, or you don't know how to treat or you're not coming back with a diagnosis. It can be difficult. Speaking personally as a clinician, we care about our patients, and we want them to get better, and it can feel frustrating, and you can be left questioning your own skills and abilities when you're not able to help a particular patient feel better. In some cases, we do try too often jump to an explanation of an alternative diagnosis like anxiety or depression when there are these unexplained, long-term symptoms. It was good that this guidance helped to steer clinicians away from that kind of initial instinct.

Q: That's very important and then you bring up another really important topic that COVID has really shone a light on, and that is mental health. During this period of time, your own mental health must have been severely challenged to 02:03:00stay in the moment and on point at all times. What have you been doing for own mental health?

BONACCI: Yeah, you know it certainly has been a challenge. I think it's fair to say it's been a challenging time to stay mentally healthy and well. I think residency training in general is a time that is difficult to maintain mental health and physical wellness. One of the things I found in residency that was particularly helpful for me to do that was to exercise regularly, and for me that was getting out and running or jogging. I did that often in Boston, and even when I was on clinical services working long hours, I often found that if I could escape after work on a night or on my one day off on a weekend to get a run in, that was a great way to get some anxiety out and get some kind of--just 02:04:00get energy out and tire myself out a little bit and calm my mind and I continued that down here in Atlanta. When I moved down to Atlanta, we adopted a dog on July 1 of 2020 right after I moved down and so in the last two years in the EIS, one of the ways I've tried to protect and care for my own mental health has been getting regular exercise with him, Jackson. We usually run a couple of miles together a few times a week. Certainly, I think one of the other ways that I've tried to care for and protect my mental health is to stay connected to my family. As I mentioned early on in the interview, I've got four younger siblings and two parents, and we're all quite close and so having FaceTime calls with them regularly has been important. And similarly with my closest friends from home, from college and from residency training, staying in touch with them over time I think has been some of the other ways that I've tried to stay mentally healthy.

I've always enjoyed cooking, but certainly COVID has given me more time to do that in some ways, and so also another way that I've tried to take care my mental health is just by pursuing things that make me joyful and make me happy, and cooking good food is one of those. While I haven't necessarily picked up sourdough bread baking like many others had during COVID, I have picked up sourdough bread buying and so I love going to our local bakeries and just trying different breads and foods and then getting to cook interesting things at home has been a fun way to do it. But those are on the lighter, more of positive sides of the mental health equation, but that's also not to discount or to say how difficult the last couple of years have been.

I don't know, I think I'm fortunate that I've weathered it relatively well, but certainly, particularly in those first couple of months when I was doing clinical work on--in the COVID ICUs and in our COVID internal medicine special 02:06:00pathogen units, I mean there were just--it was overwhelming at times. It felt overwhelming at times, both the burden of the work and just the amount of grief and sadness that we were witnessing. Certainly, in the last couple years, I found that I had been more overcome by grief and sadness in various moments than I had been in the years preceding. I've lost a couple of friends not to COVID but who have--their deaths have coincided during the pandemic, and I just found myself--or mentors who have passed--found myself stricken with grief in unexpected moments thinking about the loss of those friends and mentors. Also, just struck with sadness at different times when thinking about more broadly 02:07:00what we've been experiencing in our country and just how difficult the pandemic has been.

One of the things that I struggle with in our public discourse about COVID, and I think this extends to our discourse about vulnerable and underserved communities in general, is there's a real lack of empathy for others who are suffering or for those who face difficult circumstances. I think about this a lot and as we think about the disparities that we've been seeing, particularly in the earlier part of COVID but certainly throughout for racial and ethnic communities of color, Black--the Black community, the Hispanic/Latino community. I feel a lot of grief and sadness for the disproportionate burden that those communities and those families had borne. Again, there's a real lack of understanding and empathy about the experiences that those individuals go 02:08:00through and those families go through.

If there was greater empathy in our public discourse, perhaps more of a culture of that or more of a community-oriented culture, our overall national response may have been different. I think where a lot of points of conflict arose over time was that we have a very individualistic or individual-focused culture. When you're talking about some of the public health measures that may cause your personal sort of--they may affect your personal life negatively, but the idea is that at large, it's helping to protect a larger community. Some of those things were particularly controversial. In other countries that have perhaps a more community orientation or a less--less of a focus on the individual, some of those things were a bit less controversial. Certainly, I know I've veered a little bit here from mental health, but that's to say I think that I have been 02:09:00overcome by sadness or frustration at times in the last couple years when thinking about how our own unique American culture has, at times, hindered our response as well.

Q: During your long COVID project, that was also the period of time when vaccines became fully available to pretty much everyone, which is March 2021. It had been out since December, but really the general public started getting it around that time. Is this around the same time you got your shot or your wife?

BONACCI: Yes, so my wife got hers before me because she was actively working in the COVID ICUs. She was one of the first people in the state to get it. I think she got her first dose in December or maybe got--I can't remember if she got 02:10:00both doses in December. One of them was right around the holidays because I remember we traveled back to visit my family in Ohio, and we were very excited to know that she had that additional protection and then I subsequently think I got my first dose either in late January or early February at some point. We were ready to get them as soon as we could get them. We were thrilled to have the opportunity to be vaccinated. Particularly me, I was thrilled that my wife was able to do so because while I was working with COVID from a public health perspective as an EIS officer for the last two years of my EIS time and again the year before, she has been--she has spent all of that time essentially in COVID ICUs and working in COVID units throughout Emory's hospitals. It was a--certainly a comfort to me to know that early on she had a bit more protection from COVID. Later on, when we found that we were to be having our first son who was born at the end of December of 2021 when we found out she was pregnant, also 02:11:00knowing that she had that extra protection from COVID during and throughout the pregnancy and afterwards, that was also certainly a great relief for us as well.

Q: What did it feel like when you've got your shot in your arm for you personally? What was that feeling?

BONACCI: Yeah, I felt really grateful, certainly. My wife was the first on either side of our families to get it, and I was the second person. I just felt incredibly grateful, a lot of relief. When you look at it more in the abstract, you also--you can't help but feel amazed by the scientific effort to develop the vaccines. The process to develop them happened so creatively and much faster than historically vaccine development happens. It's really incredible not only 02:12:00that they were developed so fast, particularly two first two vaccines that were given emergency use authorization, Pfizer and Moderna, but that they were so effective in preventing particularly severe illness and preventing death from COVID. It's just really incredible. There were a lot of things that went wrong in the Trump administration's leadership of the COVID-19 pandemic, but the COVID vaccine story is certainly one of the shining moments and one of the really positive aspects of those early moments in the COVID pandemic. It's incredible, and it was awe-inspiring, and it's something I think in the history of vaccine development that will continue to be looked upon incredibly favorably, the initial development of vaccines.

Q: Yes, it was an amazing story, and then you've mentioned that Nicole was pregnant during the pandemic, how was--how did you-all handle and navigate that? 02:13:00There had to have been some anxiety surrounding that.

BONACCI: Yes, I think there was understandably a little bit of anxiety, but Nicole worked up until the day that Luca was born. Again, we felt like that this was her role and it was important. She had this training to be able just to work in COVID units and to treat patients that were critically ill, and this was part of her ongoing training and education. We knew it was a risk for her to be working in those places but also as PPE became more readily available and the supply stabilized, she got vaccinated, I think feels--she felt comfortable treating patients in that she was adequately protected. We knew as long as she used the right PPE and again had gotten vaccinated that we felt relatively 02:14:00comfortable with her exposure there. Honestly, in our day-to-day lives, we felt likely if we were going to get COVID at some point in time, that we would have gotten it more from our personal life activities than from either of our work activities, and particularly for her because she had the right protective equipment available. Even though she was repeatedly exposed at work when--as long as you have the right protective equipment, I think you feel very comfortable caring for patients. It's often when you might let your guard down in a personal setting or out in the community and you might be around somebody you don't know who has COVID that that was when we were more likely to slip up. Yeah, I think understandably a little bit of anxiety, but we just did what we could. I will say perhaps we were a little bit more cautious about COVID precautions and limiting our social circle and the ways we were interacting with people, doing it more outdoors and things like that than perhaps we were otherwise before she was pregnant and after being vaccinated.

Q: I want to be conscious of the time-- we're coming up on two and a half hours. 02:15:00There's a few other things I wanted to cover with you, but I don't think we can do it in like the next five minutes.

BONACCI: I'm happy to stay on a little bit longer. I could probably stay until five, but also if you would like to wrap up soon, I'm--whatever you would prefer is okay with me.

Q: I'm going to suggest we pause here because I'm also being kicked out of my room.

BONACCI: That sounds good.

Q: But can we finish it another time?

BONACCI: Yes, I would be happy to do so.

Q: Let me stop the recording for now. I'm going to pause.

[END OF SESSION ONE]