The 833 or 857 area code doesn鈥檛 reveal much, but the caller ID鈥擬A COVID TEAM鈥攊s like a smack to your (hopefully masked) face.
You were perhaps lucky or careful enough to avoid for eight months a virus that has killed more than 235,000 Americans and infected close to 10聽million. Now you might be a link in the chain, and this incoming call serves as a warning: coronavirus knows someone you know.
You鈥檝e seen the health department鈥檚 ads鈥斺淭he greatest act of love is answering the call鈥濃攁nd decide to pick up.
Hi, this is Marie calling from the Community Tracing Collaborative, working with Partners in Health and the Department of Public Health in Massachusetts on the COVID-19 response. Am I speaking with . . . ?
Yes, you confirm, while trying to convince yourself that this is neither scam nor dream.
We鈥檙e trying to stop this pandemic and you can help. Someone who tested positive for COVID-19 reported that they came into contact with you recently. I鈥檓 not saying you have the virus or that you鈥檙e going to get the virus, but do you have a few minutes to discuss what this might mean for you?
It means that, if you follow advice, the next two weeks will be boring at best. It also means that Marie Alden, SIS/BA 鈥21, will become a familiar, friendly voice, calling at least every other day to check in, monitor your symptoms, and help connect you with resources like food and medication.
Since April, the international studies major has been a contact tracer in her native Massachusetts, spending 20 hours a week tracking and tamping down COVID-19. She is one of nearly 40,000 crisis-time contact tracers and case investigators, according to National Public Radio, working for state and local public health departments, nonprofits, and other contractors to chase a slippery and unpredictable adversary.
They deal in sensitive, complex information, often for a little more than 20 bucks an hour, and bring dignity and humanity to data collection, talking those with COVID-19 and their contacts through their fears while facing some of their own.
For Alden, it was the unknown. 鈥淭here are just so many hypothetical reactions,鈥 she says. 鈥淚 didn鈥檛 know if people would be shocked or scared or angry and not want to share any information, so my first couple calls, I was timid.鈥 Her unease is not unusual. Matthew Reise, CAS/BS 鈥17, worried that Marylanders would try to guess who had exposed them to the virus. And Kara Suvada, CAS/BS 鈥17, fretted about fumbling over words or being bombarded by the most loquacious Georgians she called and missing key information.
None of the investigative Eagles, however, let their worries get in the way of their unselfish goal: to be good enough at their jobs鈥攅nsuring contacts are informed, tested, and isolated鈥攖o play a small part in making them obsolete.
鈥淲e care, it鈥檚 as simple as that,鈥 Alden says. 鈥淲e want this pandemic to end. Everyone wants it to end. So please, pick up the phone and help.鈥
Alden didn鈥檛 intend to be on contact tracing calls this spring鈥攐r even on this continent.
She was settling into her second semester studying social justice in S茫o Paulo in March when COVID began spreading worldwide, forcing her early return home. 鈥淔eeling a bit lost,鈥 she discovered that Partners in Health, the global health nonprofit with which she had volunteered the previous summer, was spearheading Massachusetts鈥 contact tracing program. Alden had also spent eight months speaking only Portuguese, an asset in a state home to one of the nation鈥檚 largest concentrations of Brazilian immigrants.聽
Earlier this year, the Association of State and Territorial Health Officials (ASTHO) estimated that 100,000 contact tracers would be needed to adequately identify and contain COVID-19 in the US. To reach even a fraction of that number, hiring managers have had to think outside the box: tapping both public health specialists and those with an excellent phone-side manner.
Reise, fresh off a COVID-rushed departure from his English teaching job in Merida, Mexico, brings an educator鈥檚 patience and understanding to contact tracing. 鈥淚 wouldn鈥檛 want to get that news,鈥 he says. 鈥淚t鈥檚 being there for people when they鈥檙e concerned. It鈥檚 trying to be calming, and it鈥檚 being their lifeline and their resource.鈥
Jeanette Millard, SPA/MSOD 鈥87, watched her thriving Boston-area consulting business wither to one client in a single day in March. She still projects the warmth, calm, and persuasiveness of a team builder while cold-calling contacts.
鈥淚鈥檓 somebody who wants to see problems solved. My livelihood was helping people communicate and understand each other, and suddenly I have no work and I鈥檓 helpless,鈥 Millard says. 鈥淭hen, I got this gift from the gods: a chance to help fight a pandemic.鈥 This fight is not our first. Contact tracing has existed in its most basic form since the sixteenth century when it was used to track the bubonic plague. It grew in popularity in the early twentieth century during outbreaks of sexually transmitted infections like syphilis. More recently, the HIV epidemic in the 1980s modernized partner notification processes and the development of best practices to drive testing and referrals to other health and social services.
Today, vastly improved technology and methods face a maddening foe. COVID does not behave predictably for contact tracing鈥檚 sake. It spreads quickly, shows symptoms only sometimes, and stymies our best treatment efforts.
鈥淭here鈥檚 just so much we don鈥檛 know. The asymptomatic transmission, the folks who are carriers and aren鈥檛 tested because they either don鈥檛 have symptoms or have severe symptoms鈥攖hat鈥檚 all proven to be quite a difficulty,鈥 says Professor Jolynn Gardner, director of 小蓝视频鈥檚 public health program. 鈥淚n the history of public health, it鈥檚 one of the more difficult diseases to contact trace. I鈥檓 not saying it isn鈥檛 effective, but there are so many confounding factors that people are going to slip through the cracks.鈥
The Centers for Disease Control And Prevention provide guidelines for contact tracing, but without national training requirements, a handful of universities like UC San Francisco and Johns Hopkins and organizations like ASTHO have stepped up to develop free modules. These help states and localities more quickly onboard contact tracers, providing them with the basics of communicable diseases, information privacy and ethics, and empathy in difficult conversations.聽
Data management systems differ鈥擵irginia and Pennsylvania utilize Sara Alert, while Massachusetts uses Salesforce鈥攁s do policies like texting or calling for follow-ups. But the general framework is the same. Once someone tests positive for COVID-19, a case investigator gathers the names of close contacts鈥攖hose who have been within six feet of the infected person for more than 15 minutes鈥攁nd a contact tracer reaches out to them, urging them to get tested, quarantine for 14 days, and monitor their symptoms.
Ideally, the virus will be isolated to an individual, family, or friend group鈥攂ut that assumes everyone follows the guidelines. It鈥檚 nearly impossible to guarantee that people will hunker down at home for two weeks鈥攐r that they will even pick up the phone. Tracers are persistent, often trying a contact鈥檚 cell two or three times in a row every day for several days. With unrelenting caseloads, though, they can only do so much.
鈥淵ou have to be inquisitive, have empathy, and know when to stop,鈥 says Dana Billings, CAS/MS 鈥16, a contact tracing team lead in Santa Clara County, California. 鈥淵ou can only chase down someone for so long before you have to move on to the next person.鈥
Making contact is hard enough. Getting people to then change their behavior for the greater good requires building trust, which can be a frustrating tug of war. Public health officials, who can only cross their fingers and hope that contacts stay home, know their work to stop the spread is either strengthened or stymied by each citizen鈥檚 level of faith in government and science. And COVID doesn鈥檛 just infect the cooperative.
Suvada, a graduate public health student at Emory University, spent the summer tracing myriad personalities. There was the occasional elderly contact who, happy to have someone to talk to, responded to 鈥淗ow are you doing today?鈥 with a minutes-long monologue. A grateful woman told her, 鈥淵ou鈥檙e the most helpful person I鈥檝e talked to,鈥 while a less kindly man鈥攆or whom she left a voicemail鈥攔eplied with a disturbing text message: Stupid b____, you don鈥檛 know what you鈥檙e talking about.
Nevertheless, the epidemiologist in training valued her time burning up the phone lines because it emphasized the importance of equity in her work. For every contact who stressed only about getting physically sick over a two-week quarantine, there was another who feared even more the financial ruin of 14 days without work.
鈥淵ou can know all of the data鈥攁nd I love data, that鈥檚 why I鈥檓 in an epidemiology program鈥攂ut if you can鈥檛 contextualize the people behind the numbers, then you鈥檙e not being the best public health professional you can be,鈥 Suvada says.
Worry can be a major deterrent to sharing information with public health officials, regardless of which disease they鈥檙e tracking. And while concerns like being scammed might be easier to shake鈥攆or Virginia contact tracer Tara Rahmani, SIS/MA 鈥21, sometimes it鈥檚 as easy as sharing her .gov email address or her supervisor鈥檚 name鈥攐thers linger.
As a tuberculosis contact investigator in Maricopa County, Arizona, Roel Ayala Pe帽a, CAS/BS 鈥20, has learned to fight the battle for trust on multiple fronts. He鈥檒l talk with a patient three or four times to establish a rapport and text a picture of his government ID badge to prove he鈥檚 legit. Fluent in Spanish, he also uses his language skills to connect with the county鈥檚 Latinx population鈥攐ne of the largest in the country. The stigma associated with being infected, however, can overshadow Ayala Pe帽a鈥檚 careful work andthe promise of free TB treatment.
鈥淧eople are scared they鈥檙e going to lose friends and family members because they gave them TB. They are worried that when they return to work, people are going to look at them differently,鈥 he says. 鈥淭hey鈥檙e scared of people seeing them as an 鈥榦ther,鈥 a sickly thing that can also get other people sick. That鈥檚 understandable, so we try to talk through it.鈥
Fear of illness is most palpable when it鈥檚 at our doorstep. COVID-19 has transformed our daily lives for eight months, but it can feel abstract to those who haven鈥檛 watched鈥攐r listened to鈥攕omeone fight it. For contact tracers, the reminders are intense and sudden. When she began making follow-up calls, former Massachusetts contact tracer Sophia Comas, CAS/BS 鈥17, was initially shocked at how, seemingly overnight, sprightly contacts could begin to struggle with symptoms.聽聽
鈥淚 saw that someone could be totally fine one day and then suddenly need medical attention the next,鈥 says Comas, a public health graduate student at Harvard. 鈥淚t was kind of grim to realize that,鈥 but it underscored the critical importance of checking in.
Meg Carr, CAS/BS 鈥15, was in DC visiting her college roommate in March when her employer, the Allegheny County (Pennsylvania) Health Department, announced its first COVID-19 case. She immediately raised her hand鈥攐r, rather, picked up her smartphone鈥攖o help.
Carr made her first contact tracing calls from the District and dove headfirst into the COVID-19 response while finishing up her public health master鈥檚 program at the University of Pittsburgh. While her boss established a script for calls, Carr created an Excel spreadsheet to track initial contacts, helped organize health department colleagues for calls, and hosted trainings on COVID and contact tracing basics.
As a COVID-19 epidemiologist and contact tracing lead, she compiles daily metrics, fields questions on difficult contacts and database issues, checks in with her own and other health departments, partners with local colleges to establish internal contact tracing, monitors new state and CDC guidelines (which can change daily), and even makes some of her own contact tracing calls.
Carr is inspired by her colleagues, who have poured their time and effort into an unforeseen and unprecedented health crisis, but their work is unrelenting. Since COVID hit, health departments everywhere have been all-gloved-hands-on-deck, but that doesn鈥檛 mean pre-pandemic health concerns鈥攅verything from mental health to food safety鈥攈ave receded, or that the coronavirus is behind us.
鈥淚 think the challenge is: How do we sustain this level of work for the duration?鈥 Carr says. 鈥淒espite many peoples鈥 hopes, COVID isn鈥檛 going away anytime soon. Public health professionals need more support from the general public and resources to sustain this work.鈥
Contact tracers are buoyed, however, by the courage they hear over the phone, and by relationships that are built a few minutes at a time over two weeks.
Rahmani corresponded with a contact for a week before the woman shared her greatest fear: COVID affecting her pregnancy.聽聽
鈥淪he said, 鈥業 was afraid to tell you this in the beginning, I just didn鈥檛 know [how to ask]. Since I鈥檓 positive, is this OK for my baby?鈥欌 Rahmani recalls. 鈥淪he wasn鈥檛 comfortable telling me at first, but she wanted me to know what was going on with her situation.鈥
Amid a dark time, the most rewarding endeavor is guiding someone to the light at the end of the tunnel.
Millard spent two weeks following up with a man who had grown increasingly emotional about being apart from his family. On their last call, she shared some good news: he had done his part, staying isolated while infected, and was now free to embrace his loved ones. She remained on the line and listened to the happiest of sounds: a door swinging open and a family cheering.
鈥淲hat could be better than that?鈥 she asks. 鈥淲e need to remember that we鈥檙e loving and caring people. Fear obviously makes us forget that, but we can help other people by talking with a contact tracer. So, don鈥檛 worry, and don鈥檛 be afraid.鈥
Just pick up the phone.
TRACE EVIDENCE
Our national COVID-19 case total has jumped by five figures every day since March 23, according to Johns Hopkins. Despite our protracted failure to flatten the curve, tens of thousands of contact tracers remain motivated, charting and calling through the spread.
While each organization鈥檚 outreach differs slightly, most methods are built on general CDC guidelines. Below is a framework of contact tracers鈥 fight against the pandemic:
- A patient is tested for COVID-19.
- A positive test is reported to a state and/or local health department.
- A case investigator calls this 鈥渋ndex case,鈥 collects names of recent close contacts, and relays instructions for isolation, which lasts at least 10 days.
- A contact tracer calls individuals who鈥檝e been exposed to the infected person, recommending they get tested if they haven鈥檛 already and quarantine for 14 days.聽
- A case investigator follows up if the contact tests positive.
- Contact tracers and case investigators refer individuals without access to resources like food to support services.
- A tracer or investigator makes a follow-up call every day (case) or every other day (contact) to monitor symptoms and general wellbeing.
- A case or contact exits isolation or quarantine unless symptoms remain.