When your phone rings, the caller ID shows “Public Health” with a local number you don’t recognize. Wary of scams, but also wary of COVID, you answer the call to find a stranger who knows your name and tells you that you may have been exposed. She won’t tell you who or where, because that would violate confidentiality. But she tells you to monitor your symptoms for 14 days, report them into an online tracking app, and stay home if at all possible. Then she asks whether you have any questions. Um, yeah you do.
Since John Snow investigated the London cholera outbreak of 1854, contact tracing has been a mainstay of outbreak management in public health practice. It’s where the now-familiar epidemiology curve bends and twists into the shape of an individual going about her daily activities. For contact tracing to be successful, a public health investigator must first invade an individual’s personal life to tell him that he has a contagious disease that he may have spread to infect others. Immediately after launching this personal invasion, the contact tracer has to build instant rapport with the person under investigation (now called an index case), gaining permission to probe into intensely personal details about work, play, activities, loved ones, and other close contacts. Building this kind of instant trust is perhaps most important in the communities where infectious diseases hit the hardest. These are often lower income areas where people live in close quarters. These are areas where access to health care is too often through the emergency room, rather than a trusted primary care provider. These are communities where there is a long history of little trust for the health care system on a good day, and even less when misinformation swirls through the Facebook feed that is the trusted source for news.
As the United States begins to build a contact tracing workforce to combat the COVID-19 pandemic, there are a variety of projections related to workforce size based on population levels or case counts. Various estimates suggest that America will need an army of anywhere from 100,000 to 300,000 contact tracers. State and local officials across America are mounting efforts to recruit, train, and deploy this army, rebuilding America’s public health workforce. They have to rebuild the workforce, because in 1999, Congress stopped funding the Public Health Emergency Fund.
America’s new public health work in contact tracing may be done by nurses, social workers, librarians, journalists, customer service representatives—the new grads and seasoned professionals who have been laid off or furloughed from their regular jobs that entail the type of individual contact and fact finding that contact tracing demands. But too little attention has been paid to the people who will make up this contact tracing army. For this plan to succeed, we need to ensure that contact tracing workforces are diverse enough to include workers who can connect with people in the most vulnerable communities across America.
The last massive global contact tracing effort came during the Ebola epidemic of 2014–16, and one of the things we learned there is that the success of a contact tracing workforce hinges significantly on community trust. When community trust is low for contact tracers, people being interviewed withhold information like accurate and complete lists of close contacts, allowing disease to continue to spread. On the other hand, when contact tracers have high community engagement, case interviews are forthcoming and disease spread is minimized.
That’s why America needs a diverse contact-tracing workforce, one that includes lots of representation of people from Black, Latino, and Native American communities, which have all been disproportionately affected by COVID-19. Contact tracers must also include people from systemically disenfranchised groups like the LGBTQ+ community, refugee and immigrant communities, religious minorities, and non-English speakers. Overlooking these groups can be disastrous, as South Korea learned when an outbreak occurred in the LGBTQ community in Seoul.
To that end, many state and local health departments from the CDC Foundation to Partners in Health (serving Massachusetts) to Contrace Public Health Corps (serving San Francisco) have included statements about working with “culturally diverse individuals during a time of crisis and distress” among the list of qualifications for contact tracer positions. Some departments have listed multiple languages as a plus or even a requirement, including Ventura County, California, which requires contact tracers to be trilingual (English/Spanish/Mixteco) to serve its local population.
The job listing for New York City contact tracers went several steps further. Qualifications for New York contact tracers included an “ability to understand the concepts of institutional and structural racism and their impact on underserved and underrepresented communities,” and a “demonstrated commitment to supporting communities who have experienced systemic oppression and bias.” People from highly affected communities in New York were particularly encouraged to apply.
Hiring for cultural humility and engagement at the local level is an important first step, and New York’s detailed announcement is a great example of how one deeply affected jurisdiction moved to target the most affected communities in its hiring. We are not saying, though, that the New York job listing should be replicated everywhere—the announcements should be tailored for every jurisdiction with both the size and composition of the workforce designed to meet local needs. For example, in communities with large undocumented populations, a contact tracing job listing might seek people who have demonstrated commitment to supporting migrant and refugee communities, including DACA recipients.
To support all of this, the leading national expert group on contact tracing, the Association of State and Territorial Health Officers, has created a free online course for contact tracing that highlights the importance of being able to work with disparate groups and employing cultural humility in the work of contact tracing. The ASTHO course, among others popping up, will help to introduce the work of contact tracing to the general public including vulnerable and underrepresented communities, demystifying the process and encouraging people to apply for contact tracing jobs in communities nationwide.
But it isn’t enough to have a diverse workforce for the sake of diversity. The right contact tracing teams with the right background must be deployed to cases in the right segments of the community to help ensure that efforts are successful.
In addition to this hiring and deployment two-step, public health jurisdictions should incorporate a continuous quality improvement approach to audit the patterns of active cases and spread in the community. For example, are neighborhoods with a strong ethnic component, or other cultural groups, showing particularly high rates of COVID cases? Public health leaders can use that information to update the contact tracing workforce with individuals to meet those needs on an ongoing basis as new phases of the COVID-19 epidemic ebb and flow across the nation. Getting the contact tracing workforce right in size and culture is the key to minimizing negative health and economic impacts for every American. The right contact tracing workforce, built with the right cultural and social skills for each community, can navigate us through this outbreak and minimize the spread of COVID-19.