Late last spring, when the national curve in the US had flattened to about 25,000 new COVID-19 cases a day, New York City Mayor Bill de Blasio vowed to hire 1,000 contact tracers.
The effort, mirroring those in other cities, amassed a workforce that called newly diagnosed New Yorkers, took down names of people recently in their proximity and then called each one with a heads up to quarantine and get tested themselves. The tracers then followed up and, if that person was positive or symptomatic, took down their contacts, hoping to contain chains of transmission.
At the time, tracing seemed like an ideal tool: Unlike lockdowns and masking, it put the onus on infected and probably infected people, as opposed to everyone. Unlike a vaccine, it was already here. “Contact tracing helped end the Ebola outbreak; public health experts say it can stop COVID-19, too,” chirped an April 21, 2020, headline in USA Today. A Johns Hopkins University public health expert told the paper the country could “reopen” in two to three months with contact tracing.
This January, New York City’s top infectious diseases official said contact tracing wasn’t worth it.
“Many of us for awhile [sic] now have questioned the effectiveness of contact tracing in mitigating COVID-19 given the degree of asymptomatic and pre symptomatic transmission,” wrote Marcelle Layton, head of the bureau of communicable diseases for the city’s health department, in a January 6th email to Anthony Fauci and other National Institutes of Health officials. It was part of a thread, with her counterparts in Los Angeles, Chicago, Seattle, Washington, D.C., and New Orleans CC'd.
The email was obtained by the Brown Institute for Media Innovation’s Documenting COVID-19 Project at Columbia University and provided to Motherboard. The New York City Department of Health and Mental Hygiene did not respond to a request for comment.
“There is no question in my mind that the most effective use of staffing (especially more experienced public health staff) is to focus on vaccination,” wrote Layton, “while limiting case investigations and contact tracing to more high risk settings (such as nursing homes and correctional facilities) and not trying to investigate all cases and monitor all contacts.” She asked the feds to lift restrictions on grants, so money for testing and tracing could go to vaccinations.
The email sheds light on how contact tracing went from a key part of America’s reopening strategy to a forgotten facet of a beleaguered public health effort. Officials hoped for an orderly system in which a workforce, drawn perhaps from the newly unemployed, tracked a manageable number of cases with help from infected people eager to stop the spread to their friends and neighbors. Instead, contact tracers have thrown their efforts against an autumn and winter of seemingly unstoppable spread. On the other end of the line, they’ve gotten hang-ups, refusals, and pushback based on misinformation. Sometimes, dysfunction in the system in frustrates them, causing them to question the value of their work.
“Do I feel like I make a difference? Very minimally,” Tabitha Osbourn, a contact tracer in Arkansas, told Motherboard.
A former college chemistry instructor who sought a temporary job post-burnout, Osbourn, 35, was hired in November by a company contracted by the state department of health. Each morning, she sits down at her kitchen table, opens her laptop, puts on her headset and swallows her doubts.
People used to have more questions, Osbourn said. They would ask her how long they would be sick or when they would get their sense of smell back. “Now people just seemed fatigued,” she said. “They are sick of talking about it.” She added that many people end the process in irritation over how many questions she asks about their day-to-day behavior and interactions.
Osbourn’s biggest frustration is with the system itself. Between delays in testing, results and delivery of information to her, most people she contacts were tested a week prior, she said. The lag can be even longer for those in proximity to the COVID-19-positive person. “By the time I reach them, it’s too late,” she said. “They either started showing symptoms, or by CDC standards, if they aren’t showing symptoms, they don’t have to isolate.” (The Centers for Disease Control says that after a test or contact with an infected person, people can generally stop isolating after 10 symptom-free days.)
A public information officer for the Arkansas Department for Health said that this time frame is not common. The time “a sample is collected to the time the case is referred to a contact tracer” is “about three to four days,” she wrote in an email.
“I think it could be a really good program,” Osbourn said. “I just think we don’t have the setup.”
Some countries rolled out aggressive contact tracing efforts early in the pandemic, criss-crossing the infected person’s recollections with data taken from their cell phones. The approach was a part of strict containment efforts in South Korea, Vietnam, Japan, and other countries with less dire COVID-19 stats.
Meanwhile, contact tracing in the US faced some hulking obstacles—the first being a lack of testing. Particularly early in the pandemic, the availability of tests varied by region, robbing contact tracers of the first data point on which to act. Because COVID-19 is often transmitted before the person becomes symptomatic enough to seek a test, the lack of mass testing of people regardless of symptoms allowed for large-scale hapless, undetected transmission.
“They never scaled up testing to a point where this would work,” Lori Freeman, the CEO of the National Association of County and City Health Officials, told Motherboard. “I would link the two [testing and tracing] pretty heavily and the country hasn’t cracked that nut yet.”
The task of contact tracing fell to local and state health departments, which have been beleaguered by budget and staff cuts since the ’00s recession. Almost every sizable health department hired new contact tracers, adding to the handful of health workers who had that role, but the total number nationwide by October was 50,000, half of the 100,000 that experts called for before the reopening.
The end result was that once contact tracing units were established, they were understaffed and sent into a fall and winter of out-of-control community transmission.
“I think every single local jurisdiction knew how important contact tracing was,” said Michael Reid, an assistant professor of medicine at University of California, San Francisco and an expert in infectious diseases. The problem was resources. “Some places, like New York, when they got ready to scale, they had already been hit by a tsunami.”
“I remember when the schools reopened, that’s when things got crazy,” said Jasmyn Nathanial, a contact tracer in the Bronx who was one of the 1,000 tracers hired under de Blasio’s initiative.
Nathanial, 26, returned to the US last June after scuttling around Europe, jobless. Contact tracing seemed like a good fill-in as she studied for her real estate license, and it filled a need to do something about the crisis. “I hate from the bottom of my heart seeing New York as dead and devastating as it’s been,” she said. “I wanted to help people understand they don’t have to die over this.”
She makes calls from about 8:30 AM to 3:00 PM. She works in her bedroom, the only spot in an apartment shared with four roommates that is compliant with HIPAA privacy protections. After calls, she stays connected for another hour or two of virtual meetings to keep up with information about the virus and guidelines. She also needs to maintain knowledge of food, medical and legal resources she can pass on.
In the beginning, work was slow. Cases tapered down from the spring wave. Nathanial often sat in front of her laptop waiting for new contacts to be assigned to her. As cases ballooned, so did her workload.
Nathanial then encountered a top reason that contact tracing has not proceeded as officials had hoped: People aren’t into it. If there ever was a sense of shared sacrifice and an understanding about how to contain the virus, it crumpled through misinformation and fatalism about its rapid spread.
People started hanging up on her. Soon the majority did. Among those she reached, a curious response emerged; having soaked in New York City’s COVID-19 bath for six months, whether ever diagnosed or not, people said they had antibodies guarding them.
“There are a lot of people who think they have antibodies. They are like, ‘Why are you calling? I am immune,’” said Nathanial. “I don’t know where they are getting their information from. I’m just thinking, ‘I am a professional contact tracer. I wish you would listen to me more than some WordPress site.’” (Antibodies from past infection do not guarantee immunity.)
Chary Oliveiro, 26, who took a part-time job as a contact tracer for the health department of New York State to supplement her income as a teacher’s assistant, said about 60 percent of the people she calls comply and 40 do not.
“I think people are COVID-tired,” Oliveiro told Motherboard. “I get a lot more pushback from this than I do students at the school.”
In addition to contacts of the newly diagnosed, she also calls airline travelers to inform them of the state’s guidelines about quarantining upon return. These are the people who most often dismiss her or argue or hang up.
“I have absolutely been yelled at,” she said. “This person wanted to have a debate with me. ‘There is no need to quarantine.’ I told them quarantining is just a recommendation.”
Like Nathanial, Oliveiro saw civic responsibility as a draw of the job. “I felt weird not helping out during the pandemic,” she said. She imagined reaching out to concerned people who needed help. She said she didn’t anticipate how stressful it would be. “I get anxiety talking to negative people. I didn’t realize I would be getting so much pushback.”
Freeman, of the National Association of County and City Health Officials, said another facet of noncompliance is inability for some people to comply for economic reasons. “If you are the head of the household, you might not have the ability to quarantine,” she said. “If that’s the case, then you don’t want to hear this. You don’t want to report that you’re not following rules.”
A contact tracer in the Chicago area, who wished to remain anonymous out of concern about impact on his career, said that there is a surprising amount of half-completed information in the database he utilizes. “Before I started contact tracing, my boss said this job is part therapist, part detective and part customer service agent,” he said. “I was surprised by how much of it is detective.”
He logs in and finds a file on a person identified by only a first name and a connection to COVID-positive individual. He will sometimes use LinkedIn and Facebook to try to reassemble connections from workplaces or social gatherings if the initial contact indicated that as the place of the spread.
They are sometimes startled by the amount of information the system already knows. “Sometimes people are upset if I have found them in our system,” he said, “if I already know who they have been around.”
Tabitha Osbourn in Arkansas said that she is sometimes struck by the lack of urgency in the people she is calling. “Sometimes they will ask, ‘Can you call me back? I am at dinner.’” It seems like a relaxed response to the news they were recently around someone who had tested positive for COVID-19, but as positive cases became more common, people became more blah about becoming one.
If a contact works at a school or daycare, she calls them once an hour until they pick up. She’s been frustrated as hours go by.
She is looking for another job. “I just don’t want to spend so much time on a computer,” she said. “I’m not used to it.”
Despite talk of abandoning or downgrading efforts, contact tracing may get another chance at significance in the next stage of the pandemic. The micro effort of each call had less effect when thrown against unmitigated transmission of the fall and winter.
Though predictions about the effectiveness of contact tracing seem naive in retrospect, Reid said that in a future where most people are vaccinated and daily new case counts are what they were in the spring, the more surgical solution may be more useful in containing the kinds of infection chains that will slip through our defenses.
“There will continue to be localized outbreaks,” he said. “We will have to deploy a rapid response of contact tracing. It will be more effective.”