Robert Bonacci - Session 2

Q: This is Friday, June 24, 2022. This Mary Hilpertshauser for the COVID Oral History and Memory Archive Project. I'm talking with Robert Bonacci. This is our second session. Let's begin with, or back to, your deployments during EIS if you wouldn't mind?

BONACCI: Yes, absolutely. I think we spoke last about our--my deployment to the long COVID team remotely here at the Emergency Operations Center [EOC], but the other one--so that was March 2021 to May 2021 and then the day after that ended at the beginning of June of 2021, I deployed for an epi-aid [Epidemiologic Assistance] through the Division of HIV Prevention to Kanawha County, West Virginia, to assist the West Virginia Bureau for Public Health and the local county health department in Kanawha County with an HIV outbreak among people who 00:01:00inject drugs. So, this was an outbreak that had been detected in the fall of 20--

So-- I guess to back up, West Virginia has had, in the last few years, a few different outbreaks of HIV among people who inject drugs and then more recently, had noticed specifically in Kanawha County that there was an increase in diagnoses in this county where an epi-aid hadn't previously been done. They had--were previously done for Cabell County. The bureau for public health had been in touch over time with our division and asked us to assist in trying to understand more about the care engagement patterns for people who inject drugs, so understanding little bit more about why they were or were not engaging in HIV care. Also, for those individuals who haven't been diagnosed with HIV, to understand a bit more about how they were accessing health services, HIV testing, drug use practices, sexual practices, and other things to understand 00:02:00both from a qualitative perspective--so there was a qualitative effort to understand what's going on in the outbreak. Then similarly the team that I was tasked with leading was leading a review of medical and public health records to understand from the health systems and public health side what's happening in the medical care side of things.

We were on the ground with our partners in Charleston, West Virginia, the state capital, and the largest city in the county, for the entire month of June. I was leading this medical records review, along with some reviewing public health data. We were trying to understand why these individuals were or were not engaging in care. I think one of the interesting things we had heard from local partners and from the state initially and part of the reason that had spurred our visit was that we were hearing these individuals who were injecting drugs 00:03:00and who had been diagnosed with HIV had not been in care, both before diagnosis and after, and that the healthcare systems were struggling to reach them. The majority of the people who were injecting drugs in this outbreak were White individuals who either were currently homeless or had recently experienced homelessness or housing instability.

What was interesting in the medical records review we found was that people were, in fact, accessing care extremely frequently, it's just that they were not accessing care in the ways that--I think that were normal for accessing prevention services, for accessing HIV treatment services. So rather than presenting to an outpatient clinic and seeing their regular HIV provider or before diagnosis seeing a primary care provider and getting regular preventive care, what we found was that people were visiting acute care facilities, so 00:04:00facilities like the emergency room or were being admitted to the inpatient hospital quite frequently, often related to complications of their injection drug use, often bacterial infections. We were seeing a lot of individuals being admitted for bacterial infections of the skin, of their heart valves, bacterial infections in their blood or of their bones, so quite serious complications from their injection drug use.

And similarly, during these visits, what we were seeing was that a lot of both HIV prevention and care opportunities, as well as opportunities related to addressing their injection drug use or other co-occurring conditions such as viral hepatitis, which was quite prevalent in the population in the outbreak, is that clinicians or the health systems were not addressing these particular conditions during the acute admissions. They were focusing more specifically on the acute reason why the patient was there. So one of the things that we had 00:05:00helped the health department to think through a little bit more and that the medical record review brought to light was that while these patients aren't accessing care in the traditional ways we'd be expecting, there are still a lot of opportunities, what were missed opportunities, to implement things like HIV testing, to have conversations about starting medication for opioid use disorder.

The majority of injection drug use in this population was primarily heroin and methamphetamines. For heroin use, there are effective and proven medications such as buprenorphine or methadone. Similarly, treatment for hepatitis C was pretty infrequent, so we were thinking about a holistic approach in terms of ways that they could engage patients in the emergency room, in the inpatient setting. And then similarly, I think the health department, both the local and state level, were thinking about how they could better engage patients and meet 00:06:00them where they're at, which certainly had been a challenge. A lot of these individuals again were homeless during the outbreak, did not necessarily feel--what we learned from some of the qualitative interviews that were being done by colleagues in the epi-aid were that these individuals felt quite stigmatized both from the perspective of their HIV--perceived a lot of HIV stigma, but also perceived a lot of stigma related to their injection drug use and being identified as a person who injects drugs, often felt unwelcomed in healthcare facilities, in traditional clinics or even in the emergency room. And in the inpatient hospitals, we found that another interesting and challenging finding was that a lot of these individuals were accessing care but then were leaving care against medical advice, before the end of their stay or before the physicians would have recommended they leave safely. Again, part of that was related to the stigma that they felt. In some cases, they felt that their--you 00:07:00know they were experiencing withdrawal symptoms, and those withdrawal symptoms were not being addressed.

And so, I think we were there to assist that state health department and to--both to understand more about what was happening, and I think those were some of those results, but also to think about how they could implement solutions to address some of the problems that we were discovering. I think this is where the outbreak, and the political and policy context of West Virginia, was perhaps a bit interesting and also challenging at the same time. We've known for a long time in HIV and in viral hepatitis that for people who inject drugs, one of the most effective or the most effective intervention to reduce the spread of HIV and to reduce the transmission of viral hepatitis is clean syringes, sterile syringes, and sterile injection equipment, and those are commonly or traditionally provided through syringe services programs. In West 00:08:00Virginia, and in other places across the country, we have seen a rolling back or increasing of restrictions of--or operating restrictions on syringe services programs. And so, the West Virginia context was a bit unique because they've had ongoing HIV outbreaks in various counties over the last few years among people who inject drugs and at the same time have been, in some cases, passing more restrictive legislation that either increase the regulation of syringe services programs or ultimately if--even though the laws didn't necessarily outright prohibit the operations of syringe services programs, led to some programs closing.

I think one of the challenging things about the epi-aid and about the outbreak investigation or recommendations were that both the local county and the state had each recently taken up for consideration or passed increasing restrictions on the syringe services programs that were operating in the area, 00:09:00which again if that's the most effective intervention that we had or one of the most effective interventions to treat and reduce the spread of HIV in this community makes it quite challenging. That for me was a very clear illustration of the intersections of public health and politics. You know we were drawing some parallels before in our pre-interview, I don't know if it came up in our last conversation, but certainly one of the things that has come out in COVID or one of the ongoing conversations has been whether public--the work of public health should be political or should intertwine with politics. I think there's one camp of individuals that says public health and the work that we do and the policies we recommend should be removed from political influence and from politics. We certainly saw some of the negative impacts in COVID of the politicization of the response when we were talking about the politicization at 00:10:00the level of the president previously and other levels of federal government at state and local levels.

But I think the reality is public health doesn't operate in a vacuum and whether--and it is inherently political because the work of public health intersects with public policy. Our public health powers at the federal level come because of legislation and public policy that has imbued the federal government or CDC and other agencies with public health powers. Some of the work that we do both in the Division of HIV Prevention, across the organization, and other public health organizations in the United States and across the world requires either legislation or policy change in order to improve the health of the public. Inherently, our work is political and to ignore or pretend otherwise I think is to miss an important dimension of the work. Here in West Virginia, 00:11:00this example of this outbreak, sometimes shows the conflict that can also be there in that sometimes the policy or the political side of things may not always be endorsing or promoting or legislating what are recommended best practices in public health. For me, this outbreak really had me thinking about and reflecting on that quite a bit as a particular challenge that both the state and the state bureau for public health and then us as their federal partners face in addressing outbreaks of HIV among people who inject drugs. Again, this isn't only unique to West Virginia, there are other communities that have faced similar situations previously where there have been outbreaks among people who inject drugs, but at the same time, increasing restrictions on syringe services programs. Yes.

Q: In our pre-interview or part of that we had--you brought up something, which 00:12:00I found really interesting, the term structural violence, and I know that came out of Paul Farmer article. Could you talk a little bit more about structural violence?

BONACCI: Yes, absolutely. I learned a lot about the concept of structural violence from Paul's work. I don't think he was the first person to create the phrase or the idea, but I think Paul and colleagues did a lot of work to advance an understanding of structural violence, particularly in health context. What I mean by that and what I think Paul meant by that is that structural violence is--and this is quoting from an article that that he had helped cowrite--is one way of describing social arrangements that put individuals and populations in harm's way. The arrangements are structural because they're embedded in the political and economic organization of our social world, and they are violent because they cause injury to people, typically not those responsible for 00:13:00perpetuating such inequalities.

This concept has been something that I've become more interested in as I learned of Paul's work and his writings over time. And when I think about the intersections of health equity and structural violence, I think about the lives of people who were involved in this outbreak and thinking about the structural violence that they faced, that the people who inject drugs, who are homeless or previously homeless, who had been in and out of the carceral system, that have been in out of--in prison or jail thinking about again, one of the best ways for them to be able to prevent transmitting HIV among themselves is to have access to clean needles and clean and sterile injection equipment. But there are policies or practices that are put in place that restrict their ability to do so.

They're not able to go to a syringe services program in West Virginia and 00:14:00request an unlimited number of clean needles. There's a one-for-one exchange concept based on the current regulations in the state. While it's not adhered to exactly in a one-to-one ratio for each clean or sterile needle that they hope to receive, they have to bring back a used needle that they had previously received from the syringe services program. These needles are tagged, and they're traced across time, and if somebody comes back after having had a number of--having requested and used a number of needles but doesn't bring most of them back, they're not necessarily able to get the same number of sterile syringes that they may need. It's just one example of how our structures and policies and practices can make it more difficult for people to practice healthy behaviors or healthier behaviors. I recognize that injecting drugs is perhaps not the safest or most healthy behavior, but one of the things that we ascribe to, or I think 00:15:00subscribe to, in HIV is the concept of harm reduction, which is all about meeting patients where they're at. By that, I mean that some people who use drugs or inject drugs are interested in quitting and so for those individuals, it's about providing them the resources to be able to do so, the medication treatment, if they need counseling or treatment for mental health conditions that are co-occurring, it's providing those resources. Then, there's other individuals who are somewhere on the spectrum between wanting to quit and wanting to continue using and so it's about thinking about ways to make their injection practices more safe. Syringe programs are really important tools for being able to do that, and they're also really--they're very good at doing. This is what they have expertise in, and when we're erecting restrictions and making it more difficult to people--for people to access these needed services, I think that is one example of structural violence. It's one way that we perpetuate the 00:16:00ongoing transmission of HIV and viral hepatitis within our communities.

Similarly, it is also again, our patients or the patients in this community were telling us about the stigma that they faced from healthcare providers and from others in the community. I think this goes back to a thread we were speaking about earlier in our previous interview as well about a lack of--at least as I perceive it, a lack of empathy in our public discourse for people who are vulnerable or underserved or live particularly difficult or challenging circumstances. For people who are injecting drugs or who are addicted to or have a particular substance use disorder, I think it's a really challenging life to live, and I don't think most people would choose that for themselves. There's a biology underlying substance use disorder and opioid use disorder and to not 00:17:00recognize it for the medical disease and illness that it is and the medical treatment and prevention tools that they require to help get better I think is really difficult. In our public discourse, you know what you see on the news and what you often hear people in the community saying is they're worried about dirty needles on the streets. We talk about drug user, people who use drugs as being dirty, we use judgmental language around these people and so rather than taking a more empathic approach and trying to understand the circumstances of these persons in these communities, I think we're often quick to rush to judgment, to ascribe particular morals or lack thereof to these individuals. When we see these people, our community members as either less than human or not 00:18:00the same as us, I think it's much easier to ignore them, to not be interested in providing them the resources that would help them be treated and get better and realize a better state of health for themselves.

The work of HIV and the framework that I've always felt that people who are working in HIV embrace is one that is more empathic than what the overall public discourse is, and again, one that tries to meet people where they're at. Understanding that not everybody is necessarily ready to stop using drugs, the time, in that interaction where you're meeting them, but it's thinking about what can we do in this moment and in future moments to reduce the harm to themselves and to others. When somebody is ready for treatment, whether it's for drug use or any other condition, that we're there with the resources to treat them and to help them get back on their feet. So, I know this question 00:19:00discussion started with structural violence, but it veered into a few other things there.

Q: No, I think that's all part and parcel to that. You said that they felt this population when they would come into prevention clinics or prevention services, they would feel unwelcome and the stigma the surrounding them. Is that why a lot of them would go to the ER [emergency room] because that was more of anonymous kind of setting? And also, ERs just by their own reason for being, they must accept people straight off the street, so is that what they would turn to instead of going to the services? I mean it would make more sense for the prevention services to take in the dirty needles and get them off the streets and do the one-on-one, so that you wouldn't have people going to the ERs and 00:20:00clogging that up, especially during a pandemic?

BONACCI: Yeah. I don't know that they necessarily felt particularly welcome in the emergency rooms or in the inpatient hospitals either. I think what that was a reflection of was that certain conditions-- reaching a point of seriousness where patients felt like they had to go in and seek care, and certainly, the emergency room is perhaps the fastest way to do that. In some cases, in the interviews on the qualitative side, I think we heard that when going to a clinic, just an outpatient maybe primary care doctor or an HIV clinic, it's in an office building, people are usually well-dressed. For some of these individuals who are homeless who may not have been able to bathe themselves on some day--for some days, and they might feel uncomfortable going into a building like that. I think again similarly, they may have felt that way about going into the emergency room and even may have dreaded the way they were going to be 00:21:00treated in the emergency room, but felt that they had reached a point of being sick enough that they didn't have another choice.

One of the other problems was that there were not a lot of prevention resources in the community in terms of syringe services programs. There used to be another syringe services program operating in the county at the county health department, but that had closed a year or two prior to the outbreak investigation and so I think there had been a reduction in services over time as well. So, it wasn't just that people felt uncomfortable accessing services but maybe there weren't--there wasn't enough availability, or they weren't necessarily operating at hours that the patients felt were convenient for them, and they were in traditional brick-and-mortar locations where they may not have felt comfortable going. Related to that, one of the recommendations that we made and that--some other jurisdictions have tried successfully is to use more 00:22:00community outreach services or colloquially known as street medicine or street outreach services where--or mobile services where you're bringing the medical services to where these individuals reside whether that's in a homeless encampment off to the side of--under a bridge or wherever it is that these individuals may spend most of their time and reaching directly to them and trying to reduce some of those barriers to bring them into care.

Q: So, your work continues with HIV Research Branch. Can you tell me a little bit more about what you're working on currently?

BONACCI: Yeah, absolutely. I'm in the last week or week and a half of my EIS fellowship, but since the outbreak in West Virginia, most of my work has focused on PrEP or HIV preexposure prophylaxis among disproportionally affected communities, and in my case, that's mostly racial and ethnic minority communities. I've been working on a couple of projects-- one primarily related 00:23:00to trying to understand--I guess as background, HIV pre-exposure prophylaxis has been around for about a decade now in the United States, but its dissemination or the frequency of use has remained quite low. So, there's an estimate, about 1.2 million people in the United States who have indications for PrEP as an HIV prevention tool, but somewhere between twenty to--only twenty to twenty-five percent of those individuals have received PrEP in the last year, and that is for a number of reasons. There's a number of barriers that operate at many levels, at the individual level, at the social network level, at the healthcare level, or at the structural level related to what we are talking about, the structural violence piece before.

But one of the major barriers we see in our fragmented healthcare payment or insurance system here in the United States is financial barriers. I've been working on a project with Dr. Dawn Smith and colleagues in the division to 00:24:00understand a bit more and update an analysis on estimating the number of people in the United States who have indications for PrEP that also have unmet financial needs for PrEP and then similarly as a related corollary, estimating the cost to address those financial needs. There has been, at a national level both within the federal government and within the HIV advocacy community, ongoing discussions about the national PrEP program or increasing federal resources to expand the use of PrEP and particularly expand the financial assistance that's available for patients who fall through the cracks of our insurance and PrEP assistance systems that currently exist. That's been one major project that we've been working on. I think-- the exciting--

Q: Can I interrupt you a minute? Can you explain what PrEP is exactly?

BONACCI: Absolutely. So PrEP is--traditionally has been an oral medication or 00:25:00oral medications that a patient would take on a daily basis or on an episodic basis when--to prevent acquisition of HIV, so to protect a person from getting infected with HIV. There's now also newly a long-acting injectable medication in addition to the pills that people can take to prevent HIV.

Q: So, this would be given out to someone who thinks they have been exposed or thinks they may be exposed?

BONACCI: Yes. This would be for people who are at risk of acquiring HIV. If someone thinks they've been exposed to HIV already, then clinicians would evaluate them for something called postexposure prophylaxis and so that's a related but different thing. This would be for people who don't necessarily think they've had a recent exposure but are concerned that based on the partners that they have, their sexual partners, they might be at risk of HIV. This is a 00:26:00medication that they can take that when taken consistently and in the way, that's prescribed is highly effective in preventing HIV--the acquisition of HIV. It's really--can be a tremendously powerful tool for HIV prevention, but as we've seen here in the United States, it's ensuring that everybody who needs PrEP has access to PrEP is challenging and then beyond that, ensuring that when people do have access to PrEP that they're able to adhere to PrEP and then to continue to use PrEP through periods of risk in their life is also challenging. It's thinking about what are the ways we can break down the barriers to getting people PrEP medications and then how do we support them to take them during the periods of time where it would be protective for them to be using PrEP medication.

Q: Is it a onetime dose or is it a series?

BONACCI: So, it depends. It's generally a medication somebody takes every day once a day, but there is also another dosing regimen that is used in Europe and 00:27:00other parts the world that for some people, they can take what's called episodic PrEP. They would take a couple of pills prior to an anticipated--to having an anticipated sexual partner and then they would take another pill and then one more pill after the sexual encounter. But in the United States, for the most part, PrEP is used as a once-daily pill.

Q: You were talking about the financial barriers?

BONACCI: Yes, so this project has really looked at the financial barriers, and what's been exciting about the work is that, I think it has some relevant policy valence currently. There have been a number of proposals recently for a national PrEP program or for increased PrEP funding. There are two bills that have been submitted, one in the house of--US House of Representatives, another in the United States Senate to expand funding for PrEP assistance in the United States. 00:28:00Most recently, President [Joseph R.] Biden [Jr.] in his 2023--fiscal year 2023 budget proposal has also proposed increasing, and specifically allocating funding for national PrEP financial assistance, and then in the advocacy community there have been some related proposals recently. I think this project and this work is timely in that this is an increasing point of emphasis in public policy discussions, but I think where--what the direction it's heading in still remains to be seen.

Q: Okay. Thank you for that. I think we've covered enough on COVID right now and your EIS time. I wanted to turn a little bit towards more of a personal note of your life. I do want to ask one quick question though because this man has come up in our conversation several, several times. Have you ever met Paul Farmer?

BONACCI: Yeah, so Dr. Farmer, the late Dr. Farmer, passed away just a couple 00:29:00months ago, was somebody I learned about, I think as I mentioned earlier when I was in college and learned about him from the book Mountains Beyond Mountains, which Tracy Kidder wrote to describe the work that he and colleagues were doing at Partners in Health in Haiti. I first learned about him then and then started reading some of his work, but Paul was the division director for the Division of Global Health Equity at Brigham and Women's Hospital where I did my residency. I was a resident in internal medicine and Global Health Equity jointly between--within the department of medicine, also in Paul's division. I got to know Paul through the context of my residency work and got to learn from him and his work during that time and he's been very influential in terms of how I think about health inequity and social justice, the type of physicians and public 00:30:00health professionals that we can be. Certainly, myself and people who worked with and know Paul--knew Paul much better than I do miss him quite a bit.

Q: I'm sorry. While you were there, you--yes. I'm going to just leave that. During COVID, and we're still in COVID, so I'm not going to just say it has ended. This time remains you of the importance of people in your lives and your family, and you have--you're one of five children. Were you worried about the rest your family during this period of time? Were you worried for their own health, their own safety, were you their go-to person for answers?

BONACCI: Yeah, so, yes, to all of the above. Fortunately, my younger siblings are all in relatively good health, and based on what we had been seeing 00:31:00throughout COVID for the most part, young relatively healthy people were doing okay if they had gotten infected. Before the period where vaccinations were available, I think I was definitely more worried. My wife and I were worried for older family members, my parents, her parents, and others who were getting into the age range where severe--rates of severe infection or mortality rates were definitely higher, so yeah, I think we're certainly--

We also had access to the vaccine as healthcare workers and public health workers earlier than the rest of my family did since they don't work in healthcare. I think there was a period of time where we felt reassured personally that we were vaccinated, but then, family members that I cared about haven't had access to vaccination yet, and that was certainly a period of anxiety as well. I think knowing that my family members all had opportunities to get the full vaccine course and subsequent boosters that have been recommended 00:32:00has been reassuring and has all helped us to feel a bit more comfortable about seeing each other in gatherings. Since none of them live down here in Georgia, in order to see them, they're either traveling to us or we're traveling to them and--yeah.

Q: Was there a time when you couldn't see them?

BONACCI: Yes, early on in the early months of COVID, certainly when I was in Boston in March 2020 onward and when my wife was down here in Atlanta, we were not seeing family at all. We couldn't travel anywhere actually. Our hospitals basically asked employees, and clinicians in particular, to not travel anywhere because they were anticipating needing all hands on deck in a clinical sense, so certainly, we couldn't travel at all then. I'll say my wife and I have missed--through residency and medical training and generally, you miss more holidays than you'd like, but certainly we forewent attending as many holidays 00:33:00as we normally would have because we were worried about bringing COVID to the family gatherings. It's not that we didn't meet or gather all that, but certainly, we observed a more limited Christmas, or instead of traveling to see both families over that holiday, we only saw one so that in case we had carried something with us, we weren't bringing it from one household to another. My wife and I, but also my siblings and my parents and parts of her family have definitely been more careful in the last few years in terms of our travel.

I think people feel a bit more comfortable gathering now, now that there's good access to vaccines for everybody. That also fluctuates too with COVID case rates in the community, so at periods of time when there are less cases, I think we feel more comfortable traveling. In periods of time when cases are really high or we know that community levels of transmission or through the roof, so to speak, we're a bit more cautious about traveling or the ways we travel whether 00:34:00that's by airplane or instead--sometimes we opted to travel by car because you're reducing your exposure to others in an enclosed space during that time. Yes, certainly COVID had changed the way that we--changed the frequency that we gathered at and sometimes changed the way that we would spend time with each other.

Q: Yes. When you were working in the ICU, did you have ways of returning home, rituals that you had when you left the hospital or came home so that you didn't spread it to anybody who was at home with you although you were living by yourself?

BONACCI: Yes. I did have a roommate who was also a resident at the time, but I wasn't living with any family any longer. I'd say, I don't know that I observed any specific rituals because--well, I guess, that's not true. I suppose particularly in the beginning when we didn't know a lot about COVID, I was very careful about what we were bringing into the house. For example, we would go 00:35:00into work and then you would change into a set of scrubs and then you would come home and as soon as I hit the door or before I left the hospital, I was often changing again out of that pair and then once you got home, I was either sanitizing or heading straight to the shower. We realized a couple of months in that some of that was probably not necessary. I think some of those rituals waned a little bit.

I wasn't a person who was wiping down all my groceries, but I very much remember other friends or family members or people in the community would wipe down all of their groceries, were wearing gloves to the grocery store, especially in the beginning when it wasn't exactly clear whether this was airborne transmission or whether it was transmitted by droplet or close contact, and there was a lot of fear in those early months about COVID, the rituals were certainly heightened. 00:36:00We still have remnants of these rituals around our house now. When you look around in our cars, we've got hand sanitizer bottles that we didn't used to keep there regularly. On our kitchen counter, we have a hand sanitizer bottle and so I think we do use that more now than we did before COVID, but it in some ways, those are remnants of those early months as well when we didn't have such a good understanding of how COVID was transmitted. And that's--that's not diving into the mask piece either.

Q: Yeah. Well, we could dive into the mask if you want to because at the very beginning, you weren't masking at all.

BONACCI: Yeah.

Q: But we were wiping down our groceries.

BONACCI: Yes, yes, that was in hindsight, I can imagine from the perspective of just people in the general public was a very confusing time, and I think that there's still a lot of anger or disappointment about how that was--how that 00:37:00communication was handled. I think you know, certainly, from a hospital perspective and being a clinician, there was very early emphasis on wearing proper protective--personal protective equipment and wearing masks. There was some debate about which was the right type of mask, whether it was a surgical mask that was needed or an N95, but certainly, there was an emphasis in the hospitals on needing to wear masks. But the messages that we were getting as just a citizen in the country and as a member of the general public was that we shouldn't be masking, we don't know that masks are beneficial, or in some cases, you were hearing that masks don't work.

Really, the underlying reason was that it was--or at least as I interpret, one of the underlying reasons was that it was very important to preserve the PPE supply for healthcare workers and frontline workers who were being exposed and needed this PPE, but that wasn't really the message that was being communicated. Instead, there was a message about these aren't particularly effective or 00:38:00efficacious for the general public, so don't wear them when in reality, over time, I think we learned that masks can be quite effective. Again, there is debate that continues today about what is the appropriate type of mask to recommend. We certainly know N95 masks are more protective than surgical masks, but I think there have been conflicting recommendations about which type to wear.

But certainly, in those early months was a very confusing time when people were initially being recommended not to wear them, then the recommendation changed and focused on, well, it's okay for--or we recommend that individuals wear cloth masks, again to preserve the medical supply PPE for frontline workers and clinicians. You know, in reality, it's probably the case that cloth masks aren't particularly effective for the most part. Again, it depends a little bit on the materials, number of layers, whether there's filters in between those, and then that message matured a little bit, and there was more of a focus on surgical masks or N95s and that also mirrors as they became more available and the 00:39:00supplies stabilized that the general public was able to access those more. But certainly from a crisis communication or public health emergency communications perspective, I think the masking piece was really complicated, and also if people could go back and do it again, I think we would say there were ways that we could've done a lot better from a public health, federal leadership perspective.

Q: Right. Well, the PPE had the supply-chain shortages, where most of our masks came from Asia, which is also where most of the virus was coming from.

BONACCI: Yes.

Q: And that had a lot to do with supply chain.

BONACCI: Yes, absolutely.

Q: Just didn't see that and 20/20 is hindsight, hindsight is 20/20, gosh. The other part of working for you as an EIS officer, it was completely teleworking, 00:40:00and it completely changed the landscape of our work. CDC had to go all virtual within a week. That's a lot of people working virtual very quickly, and I know there were some people who were already teleworking a couple days of the week, but this is a lot of people being told to go home and here's a laptop, good luck.

BONACCI: Yes.

Q: You were training during this period of time, so did you feel that your EIS--well because you don't have anything to compare it to, but do you think you've got your EIS experience the--well, you got the COVID EIS experience is what I'm trying to say, and do you think that was a hindrance? There was not a lot of collaboration, your face-to-face time with people that you were hoping to make relationships--build relationships for future work, was that a big 00:41:00challenge for you guys?

BONACCI: Absolutely, I think as it has for many or maybe everybody's life, COVID turned everything upside down, and that's particularly true for training programs, academic programs. To think back now at the very end of the two years of EIS and say that this was anything close to what I expected EIS to be before I applied would be completely false. I mean it has been completely different than I think any of us expected. One of the challenges was that we were onboarding in a telework setting, in a completely remote work setting. I think, for example, the class before us, the 2019 class who also had to deal with COVID, they at least had six or seven months or eight months where they had a normal EIS experience, had met many of their supervisors and mentors and colleagues in person, and at least when they had to transition to telework had 00:42:00this established network of relationships to work through and with. For us, it was definitely more challenging because in many cases, we hadn't met any of these people in-person, our supervisors or the EIS leadership, our co-officers, and so I think that definitely made the experience challenging.

I think the thing that, as I reflect on what it's been like to be an EIS officer in the last two years that I feel like we've lost the most was one, the opportunity to build relationships, but two, I think as trainees, we lost a lot of those opportunities for informal mentoring that happen when you're in-person together. By that, I mean like sometimes you'll attend a talk and people will linger around for question-and-answer after a talk, and that leads to new threads of conversation or new ideas there or it leads to meeting somebody you might not have met before that, and that becomes a new work colleague that you continue to keep up with. There no longer was the, you know your supervisor or a 00:43:00mentor is just down the hall, you could go knock on their door and see if they were free for fifteen minutes to ask a quick question, and that ends up turning into an hour-long discussion about what it's like to work at CDC or whatever it is about your personal life or professional life. I think a lot of that was lost when we transitioned to Teams and Zoom, because Teams and Zoom revolve around being scheduled for an hour call or a half-hour call and so there's not necessarily a lot of time to linger. That's what I mean when I say the informal mentoring, I feel like is one of the biggest pieces we lost in addition to relationship building.

You know on the other side of things, my class, the class of 2020, will certainly look back on this time and be uniquely remembered. We came in as EIS officers during the largest emergency response in the agency's history, and what I--hopefully for our future will continue to be the largest emergency response for the foreseeable, upcoming decades. And we got to be at the center of that. 00:44:00We were called to deploy to different jurisdictions, to work remotely in emergency operations center, to do work in our divisions alongside of that. We came to EIS interested in learning applied epidemiology and shoe-leather epidemiology, and we got a chance to do that in the largest, most significant pandemic of basically all of our lifetimes. And so it's hard to know, it's hard to compare our experience to prior officers, I think it's just very different. There are things that have been unique that have been beneficial from a learning perspective, but certainly, the telework or remote work, learning remotely has been particularly challenging. I think we've had to be creative and attentive to detail and committed to our work and thinking about ways to make sure that we're maximizing our learning experience and our fellowship experience. Yeah, it's been an interesting couple years as an EIS officer.

Q: Yes, and sometimes hard to manage your time when you don't really know if you're working a nine-to-five job or is this going to be twenty-four hours a day because there's really no line between when you stop work and when you start work anymore.

BONACCI: Yeah, yes, yes, absolutely. Yes, that's a whole another sort of thing figuring out how to balance this new style of work. I went from working in the hospital six days a week, and even during the start of COVID, we were working in-person all the time because that's the nature of clinical work, and as soon as I moved to Atlanta, that transformed completely. I went from seeing my work colleagues every day and seeing patients every day to working in my home office, what you see behind me here. From connecting to--trying to meet new colleagues, trying to meet the people on my team and in my branch, trying to meet other EIS officers, doing that all remotely, trying to learn remotely during summer course, trying to understand the Division of HIV Prevention and start to learn about potential projects I could work on. It was just--turns your work world 00:46:00upside down. I feel much more comfortable doing it now two years in, but those first months were a particular challenge in trying to not feel too lost as an EIS officer, and that is no fault of my supervisor. It was difficult for everyone to try to figure that out and navigate that.

Q: Yes, I wonder how this is going to reverberate down through the generations as we go forward? There were two graduation classes in colleges and high schools and how that's going to affect our future, their futures, and how they learn. What do you think was your biggest professional challenge during this time?

BONACCI: I think my biggest professional challenge was what we just touched on, which is how to work and how to learn in a remote environment. I don't know that I was particularly well-suited to it when EIS started. It certainly wasn't what 00:47:00I expected to be starting when I had originally applied to EIS and then committed to once they made the offer that I was accepted. It was really difficult, it wasn't that there wasn't support for us as trainees, it's just that I think people were figuring out what the best ways to support us were, and we were also trying to learn and express where there were gaps in the support we needed. It's made all the more difficult when you're not doing it in person. And so I think trying to feel like you both were learning the things you wanted to learn in EIS and meeting those professional milestones, but also not just learning but contributing to the work of public health, contributing to the work of my division, to the work of our emergency response. Feeling like we have this unique training and background even before we reached EIS as either clinicians or PhD epidemiologists or veterinarians or nurses or dentists and how do I 00:48:00translate that, that experience and expertise in a way that's useful. The challenge felt even more heightened in this kind of remote work environment.

Q: I wanted to go back to what--in our pre-interview, you were thinking about leaving clinical work to go and become an EIS officer during a pandemic. You kind of double thought that and thought is this the best use of my talent especially during a pandemic, and that was what I was thinking about when I asked that question.

BONACCI: Yeah, no, I--that was something particularly early on, I think I've since sat with that and feel a bit more comfortable about my decision. But early on, I really--it's not that I was actively thinking about leaving or exploring leaving, but I often ask myself like am I best suited here doing what I'm doing, learning, and working as a public health professional in the EIS program where clearly, I don't have quite as much expertise but I'm here to learn and build 00:49:00that. Whereas just the month before or even the weeks before I moved, I was working on COVID services helping to treat patients in the midst of the surge, the first surge in Boston, and that's really a tangible way to contribute. I had spent four years of residency training to build those clinical skills, and at the very end of my residency program, it just so happened that I had developed a really relevant skill set to treat patients when it was again an all-hands-on-deck, all-clinicians-needed situation in my hospital and in our region. To leave my residency colleagues or my younger, more junior colleagues behind, they were certainly fully capable, it was more just I was wondering was my effort best directed doing the things I had previously been doing, the clinical care and maybe not spending my time trying to learn more about applied epidemiology and public health, which is really important work and I'm glad I 00:50:00stuck with it.

But in some ways, in the middle of pandemic where people are dying in the hospitals can feel a little bit more nebulous or removed from the immediacy of the problem. In clinical work, you're touching the patients, you're seeing the patients, you're witnessing and accompanying them in their suffering, and you are trying to develop diagnostic and therapeutic plans to help them weather this COVID illness and come out on the other side. Certainly, I think the public health work was essential to the response, but it feels maybe a little bit more removed from people's lives at times, particularly at the federal level where we're operating at a much higher level of public health instead of perhaps at the local level where that's where the rubber meets the road so to speak.

Q: Yeah. Have you seen people around you change their opinions, their day-to-day activities, or your relationships with them in response to the pandemic? Like example, maybe you have friends who didn't--who due to their vaccination status, 00:51:00you just decided not to see them for a while?

BONACCI: Yeah that, you know, I think fortunately in my closest circle of friends, for the most part, I haven't seen a lot of those relationships change or a lot of points of friction around that. But I do reflect on my wife, and I have either friendships or people we know in our family or in our friend circles who I think maybe share different views than we do about the importance of COVID and the importance of trying to protect others from COVID. You know--I don't know if, perhaps, I don't know, frayed relationships is the right word, or we've withdrawn from some of those relationships without necessarily a particular point of conflict or even that person knowing. But I think particularly around misinformation and vaccine status or willingness to wear masks. I think before 00:52:00vaccines, this was even more relevant when there really were not a lot of ways to protect each other from COVID, I think these were--felt even more salient then and still do now in some ways.

I think one of the other things that you realize is that some people don't share the same belief or view of science as you do and of--the benefits of vaccines. Yes, I don't know, I think that absolutely has been--it hasn't been challenging for most of my friendships and personal relationships, but I think there are some folks that that were either acquaintances or friends or distant family members who you see them putting out opinions on social media and things like that, and it just--I think your instinct is maybe to pull back a little bit from that relationship sometimes because it seems like in some ways, they don't--they 00:53:00may not share the same values as you. It's a tough thing to navigate because you may have a long history and long-standing relationships with some people and then at the same time, there might be an issue like protecting yourself or others from COVID that feels so important to you that it can be hard to rectify that relationship or to square that relationship when somebody doesn't share your views about something that you feel are so central to your health, particularly I think about in the context of protecting the health of others. Yeah, so I certainly identify with that having happened throughout the pandemic.

Q: You think of the loss of community. Now that we are two years into the pandemic, do you think we're going to think of COVID more as an endemic sort of thing that we're going to have to take care for each year rather than a 00:54:00pandemic? Do you think the pandemic will come to an end or will it just become an endemic thing, meaning it'll always be there, we just have to treat it?

BONACCI: Yeah, you know that's the million-dollar question. Before, you had asked if family members, if I was one of their go-to places for questions about things related to COVID, and certainly throughout, I had a number of family, friends, I think my wife did as well, who were constantly asking us questions whether it was about testing guidance or quarantine isolation guidance or risk of this, risk of that, is it okay to travel here, can I go to Greece on vacation, what do you think? And I loosely associate that with the same question in the sense that what I'd like to say is that first I--anytime I'm asked a question like that, I always try and approach it with a degree of humility. I think it's most important and honest to say that the reality is I have no idea 00:55:00what is likely to be the case or at least, I should recognize that I don't think we in public health and in general, those working in health, will know exactly that answer. It seems to me now that this has been going on for a couple of years and we have seen waning and waxing of COVID at various times and the appearance of new variants, I would expect that COVID is going to be with us here for a while. How long exactly, I don't know, and what that looks like exactly, I'm not sure, but over the last couple years, we have worked to learn to live with it, and I think we will continue to need to do that for the foreseeable future.

Learning to live with it though, I think that that can mean a lot of different things. That might mean, depending on what sort of public health policy path people choose, could mean keeping a lot of mitigation measures in place, trying to continue to increase vaccinations, people continuing to wear masks, in other places, you know people may not feel comfortable or happy with those 00:56:00restrictions at all. Living with COVID, some people interpret living with COVID as, oh well, it's around, it's going to be a part of life, and I'm done wearing my mask, and you know if I get COVID, so be it, and if I spread COVID, so be it. I'm just representing a little bit of an extreme example, but I think there's--it's hard to know where the future is going to go with COVID, but I try to err on the side of caution in that I still try to take some precautionary steps and particularly with an eye towards trying to protect others who may not be able to be vaccinated or who are vulnerable because of immune or other health conditions that their body doesn't respond to vaccination with a stronger immune response. And so I think it's definitely here with us for a little while. How long exactly, I don't know, and what those variants will look like, I'm not a hundred percent sure. But, yeah, I think anybody who has that crystal ball, I'd love to meet that person, but certainly, I think--

Q: We all would.

BONACCI: --yes, no, it--yeah, I think it's definitely going to be around with us for a bit at least.

Q: Right, and you did have that project where you were working on long COVID, so.

BONACCI: Yes, and to that point, even if the day-to-day COVID infections go away, I think we will still be faced with the aftermath of many, many people, thousands upon thousands or more who are dealing with longer-term effects from their previous infections. And so even if COVID does go away, I don't think--and certainly its impacts both on our society and on individual patients that I think we will continue to bear these scars for many years to come.

Q: Yes, I agree. Well, we're coming up on this last question that I always end with, and that is what else have we covered that you'd like to share? Is there something from your clinician days, some experiences there or--? I'd leave it there.

BONACCI: You know I think I'd like to share that I remain hopeful for our future. I think there's certainly a lot to feel upset about or cynical about after the last few years or after the last two years of the COVID response and what our political environment has been here like in the country. Some of the--what feels like a fraying of the fabric of community, how long is the pandemic going to be with us, there's a lot that you could feel pessimistic about, but I think I still feel hopeful that there are things that we can do and there are ways that we can improve our response not only to COVID, but to improve our health system. I hope COVID serves--continues to serve as a wake-up call for our need for a more equitable system of healthcare in the United 00:59:00States. Again, I think maybe if I haven't said it explicitly, I hope it serves as a catalyst for more empathy in our public discourse, more, excuse me, understanding and care for others. I would love for there to be a greater importance put on thinking about others in our community and community--a sense of collectiveness or fellowship among all of us. I'm hopeful that some of that is still possible.

And also there are ways, even if COVID doesn't go away, there are ways, there are systems and protections that we can put in place with the appropriate resources to protect not only our most vulnerable but also to allow people to return to some semblance of their lives whether--it may not be their pre-COVID 01:00:00lives, but yeah I would share hopefulness in the future, but not--it's not an idle hopefulness, it's the type of hopefulness that that's going to take a lot of hard work on the part of each of us. I say that both each of us within the public health community, but each of us as members of the larger--of our larger society both locally within our towns and cities and as members of a larger society here in the United States and more globally as well. I can foresee a better world for us, but it takes a commitment to caring about others and to providing resources to individuals who need those resources and to thinking about things in a more collective sense rather than perhaps the--often the individual frame that we think about them here in the United States I feel like at least. Yes, maybe I'll pause there.

Q: All right, well, I want to thank you, Rob, for taking the time with me today.

BONACCI: Thanks Mary, I really appreciate it, thanks again for the invitation to do this.

[END OF INTERVIEW]

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