The contact tracers caring for America, even if the country doesn’t care

As California’s coronavirus cases soared past 420,000 in July, Michael Reid, the director of UCSF’s contact tracer program, took his moonshot. His staff needed something special — the right cheerleader to galvanize them for the hard work ahead.

He called Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases.

“I was like, why not invite Tony Fauci?” Reid tells Inverse. “And he said yes.”

Fauci spoke to the 237-person team on Friday, July 24 during a meeting that Reid describes as part team review, part “pep rally.” It proved to be a bright spot in an otherwise rough week for California. That week the state broke the previous single-day record for new coronavirus cases, recording 12,807 new cases on July 22.

A T-shirt-clad Fauci spoke to Reid’s team over Zoom:

“It just gives me a great pleasure to be here with you – to say hi, to honor you and recognize you,” he said. “Know when I am sitting in the White House situation room almost every day as part of the coronavirus task force, I often think about and talk about what people like you are doing.”

Contact tracing is a centuries-old public health strategy that existed long before Covid-19. It was used to trace an outbreak of bubonic plague in northern Italy in 1576 and, as recently as the 1980s, to trace HIV outbreaks. A contact tracer will call someone who tests positive for a disease, ask them some questions about symptoms, and then reach out to anyone else who may have been exposed to coronavirus via that person. Those people can then self-isolate and cut off the chain of transmission.

Much of the early buzz around contact tracing was centered around technology. Singapore’s contact tracing system involved an optional government-sponsored app called TraceTogether, which uses Bluetooth to keep an anonymized log of devices that came close enough to someone with Covid-19 to warrant concern. Apple and Google collaborated on a contact tracing app called COVIDWISE, which debuted in Virginia on August 12.

Even with apps, a contact tracing workforce estimator created by scientists at George Washington University estimates that the United States still needs humans — as many as 369,000 humans — to do the job, based on case counts from August 5.

A more general rule of thumb from the National Association of County and City Health Officials suggests we need about 30 contact tracers per 100,000 people during this pandemic. That’s twice the number we need in non-pandemic times.

“If you aren't a genuinely empathetic person, please don't apply for these positions.”

Reid’s contact tracers in San Francisco, like any team, are tasked with calling as many Covid-19 patients and their contacts as possible. They dive into the lives of the countless Californians who have had personal brushes with Covid-19. Those calls can be hard on those who receive them. They’re hard on the callers, too.

“You’re calling people every day who are full of anxiety. They're facing tremendous upheaval,” says Reid, “I don't want to overstate this, but I think many [contact tracers] do experience vicarious trauma from the experience.”

The people who pick up the phones are the heart and soul of contact tracing efforts, says Steve Waters, the co-founder of CONTRACE, a company founded in 2020 to supply contact tracers. They supply a key ingredient that makes these efforts successful: empathy.

“If you aren't a genuinely empathetic person, please don't apply for these positions,” Waters tells Inverse.

The best contact tracers know the job is as much about compassion as it is about disease surveillance. Compassion is a renewable resource, but feeling too much of it can be overwhelming. Waters says that, without adequate support, “we're starting to see contact tracers burning out.”

Contact tracing programs from California to Texas are actively preparing to combat something called compassion fatigue, which is a symptom of burnout that has been studied in healthcare workers but can also leave contact tracers feeling drained as the pandemic continues unabated in the absence of a national strategy to stop it.

“They're working really hard making lots of phone calls at this moment, so being attentive to that potential for burnout is something that is top of mind for me for sure,” Reid says.

The talk from Fauci, Reid explains, was meant to ground the tracers: It was “just a great morale-boosting event."

And right now, keeping spirits up is essential.

Not a call center

At 8:30 a.m. every morning and 2 p.m. every afternoon, the volunteer contact tracers at the University of Texas Austin tune into a “huddle.” Darlene Bhavnani, an epidemiologist at UT Austin’s Dell Medical School who oversees the program, delivers new “notes of encouragement.” It’s not exactly a pep rally, but it does the job.

She tells Inverse her remarks sound something like this:

“Any chain of transmission that we can cut short is going to be effective, so even if it feels like cases are on the rise and that we can’t call every single case at the moment, those cases we are calling and cases we are reaching in time will help to effectively curb transmission.”

Bhavnani’s pep talks are precise, as is she. The contact tracing effort at the University of Texas isn’t a “call center” she emphasizes. “It’s much more than just having callers call out. There’s a science behind it.”

Contact tracing starts with a list of people who have tested positive for coronavirus – often provided by a medical clinic, lab, or hospital. With that list in hand, the contact tracers start making calls. They start by identifying themselves, and then the script diverges depending on whether they’re talking to a case or contact.

If they’re contacting someone who has tested positive, they may try to help someone remember who they have seen recently or connect them with services they need to quarantine safely. Contact tracers can then reach out to contacts and alert them to the fact that they may have been exposed. They never reveal the name of the person who has already tested positive.

Bhavnani is clear: Contact tracing isn’t going to end the pandemic. But it is a critical measure that can help reopen states, alongside decreasing case counts and increasing testing capacity.

A “frontline guide for local decision-makers” created by the Georgetown University Center for Global Health Science and Security suggests that 95 percent of contacts should be reached if we want to live some version of normal life. If we want to think about initial stages of reopening, the guidance advises reaching 75 percent of contacts within 24 hours.

New tracers can get caught up on that science over a couple of days. At the University of Texas, the team uses Johns Hopkins’ online course for its scientific and data privacy training. But that alone can’t prepare them for the reality of speaking to someone who is currently living through Covid-19.

That’s why they supplement that training with an internally created compassion fatigue course. In California, Reid has psychologists come and talk to his team about the idea that compassion itself can be taxing.

Compassion fatigue is described as a type of “secondary traumatic stress” that comes as a result of caring for others in distress. It’s most commonly documented amongst healthcare workers, like Intensive Care Unit doctors or psychologists. A 2015 review paper in the journal PLOS One estimates that between 7.3 and 40 percent of ICU workers experience compassion fatigue based on two previous studies.

One 2018 paper on compassion fatigue in nurses explains that they become “predisposed” to compassion fatigue through constant exposure to suffering, high-stress environments, and the “continuous giving of self.”

Charles Figley, the founder of Tulane University’s Traumatology Institute, likens compassion fatigue to the constant prodding of a recently healed wound. There’s no literature on compassion fatigue and contact tracers yet, but he says it’s fair to say they’re at risk for compassion fatigue-mediated burnout. Even if they’re not pulling shifts in the ICU, one can still hear a lot in a phone call: the tremble in someone’s voice, the eagerness to speak to someone who’s not in their quarantine pod, anger that they’ve been contacted in the first place.

“The contract tracers are, in effect, scraping some of the wound in order to get information,” he says. “But at the same time, they have their own wounds from past interviews.”

Public health student Addison Allen, 20, has heard it all since she first applied to be a contact tracer in early April. She’s a volunteer contact tracer at UT Health Austin, but she’s been promoted to a contact tracing lead.

“The contract tracers are, in effect, scraping some of the wound in order to get information.”

“There’s definitely some calls where you do really bond with the person you’re talking to, and they’re really thankful that you’re calling because this is a time where a lot of people feel really alone,” Allen tells Inverse.

“I’ve had people cry with me and just be sad about what’s going on in their lives.”

Allen says she recently spoke to a woman who had just tested positive for coronavirus. The woman told her she was self-isolating in the house. But that morning her child had knocked on her door and waved at her. “She just started bawling,” Allen says.

She asked Allen when it would all be over and when she could hug her child again. She said she felt like a bad mother.

The 20-year-old rising senior at the University of Texas replied:

“You’re actually being a great mother by protecting your child by isolating. I know it’s really, really hard, but it’s the best thing you can do for your family’s safety.”

The ability to empathize is a huge part of being a good contact tracer. But it’s also part of the job that puts tracers at risk emotionally.

In their guidance on contact tracing, the APA suggests psychologists who may experience it aim to create a “semi-permeable membrane around their hearts.” The trick is to let in just enough, but not so much that you’re drowned in another’s emotion — especially since contact tracers have to move on to the next call. The costs of failing to do so are high.

One of the most common symptoms of compassion fatigue is numbness or learned indifference to suffering, Figley says. That’s particularly bad news for a contact tracer. It’s the dulling of the most important tools contact tracers need to use to do their essential jobs: emotional intuition and understanding. As both Bhavnani and Allen note, there are cases where a pre-written script can only get you so far.

For those moments, Allen says compassion fatigue training is “really big.” She copes by keeping her eyes on the big picture.

“It can be pretty draining by the end of the day, sometimes we’ll have lots of calls that are just harder than others. But it’s also just very satisfying to know that we are making a difference.”

“Resetting” the messaging on contact tracing

Contact tracers are intended to be a line of defense between us and the apocalyptic world of true lockdowns, says Waters, the founder of CONTRACE. Instead, he says some see them as messengers of the apocalypse.

“Contact tracers regularly come across people who believe that contact tracing is an infringement of their personal freedoms or a government plot to control them in some manner,” Waters tells Inverse.

“To be explicitly clear: it is not.”

Contact tracing is a basic public health tool that has existed for centuries outside of political machinery. (It dates back to the 16th century, after all). But because of the scope of the pandemic, it has been incorporated into political life.

After the Covid-19 Testing, Reaching and Contacting Everyone (TRACE) bill was introduced to Congress on May 1 — it aimed to allow the CDC to provide $100 billion in grants to support Covid-19 response, including contact tracing programs — conspiracy theories spiraled.

As a report from the think tank ISD Global notes, anti-contact tracer social media activity became enflamed in the spring. An April 29 video called “beware contact tracers” posted by an “influencer” for the conspiracy group QAnon calls contact tracers the “medical Gestapo.” She likens them to a “grand inquisition.”

The video now has over 300,000 views on YouTube. Between April 29 and May 14, the video was interacted with 16,000 times on Facebook and Instagram and shared 4,800 times, ISD Global reports.

If you ask Waters, the key mission of contact tracing has gotten lost in translation as these videos push misinformation. Contact tracing “has nothing to do with politics and that participating in contact tracing is not a political act,” he says.

Bhavnani and Allen are both adamant to not reveal the names of people who test positive for coronavirus. They don’t turn files over to the police. Reid adds that they also don’t turn names over to immigration agencies like ICE.

Many contact tracers aren’t even public health officials by training. Reid estimates that 60 percent of his workforce are librarians. Others are city attorneys, public defenders, tax collectors. This portion of his team is paid through the city government.

Waters ventures a guess that about 90 percent of contact tracers are paid, but not all of them are; those at the University of Texas, Austin, like Allen, are volunteers. The remainder of Reid's team in San Francisco are students at UCSF's medical school, San Francisco State University of City College San Francisco. They're doing it for course credit.

“Several months ago, many programs launched using volunteers, however, most of those have now transitioned to paid positions,” Waters explains. “I think the nature of contact tracing makes it a challenging position to hold long term as a volunteer due to the mental and emotional strain of the work.”

The bottom line is that contact tracers are often not career public health workers. They’re college students, librarians, city assessors, out-of-work journalists, and other professionals.

They’re sometimes portrayed, often by conspiracy groups like QAnon, as something more sinister. Myths surrounding who contact tracers are or what they do can fuel mistrust of contact tracers that makes some wary of their recommendations (especially the most common one: to quarantine).

When asked how she might deal with a contact who is unwilling to isolate, Bhavnani doesn’t point to language her tracers use to help convince people to quarantine — though they are trained in “effective communication.” Instead, they deal with antagonistic calls with the same tools they use for the sad ones: meeting people where they’re at emotionally and getting to the root of the problem.

“I totally understand why they’re frustrated,” Allen says. “But trying to empathize with them to the best of our ability is the best way to go about it.”

Usually, antagonism stems from bigger issues. Sometimes it’s because they’ve already been contacted and “they’re just kind of overwhelmed” says Allen. Other times it’s because they feel they simply can’t comply with what tracers are asking them to do. Can they afford to feed their family and self-isolate? Do they even have the space in their home to do so? Is their employer going to even allow them to take time off?

Some of those problems can be solved. For instance, should someone have food needs, the tracers at the University of Texas will contact food banks or a non-profit to get them what they need.

Not all problems are solvable. Those are among some of the hardest moments for contact tracers, says Bhavnani, and it’s a major impetus behind why they developed their compassion fatigue training in the first place.

“It can be really emotionally draining on our tracers to listen to the stories and then not be able to fully help meet all those needs that go unmet," she says. "There are some needs that are beyond our control, and it can be difficult and emotionally stressful to listen to that.

So we have compassion fatigue training.”

Launching a public health career

Allen says that she’s reached out to professors hoping that they might encourage students to volunteer as contact tracers. There are people of all ages on Allen’s team, but “I do think there is a younger demographic working on contact tracing, at least at UT Austin,” she says.

There are other examples of students stepping up as internships and summer jobs are canceled. When the Ohio Department of Health asked for contact tracing volunteers in March, they received 1,200 applications. More than 900 of those applications came from college students. In Florida, at least 400 students are working at state contact tracing programs, The Tampa Bay Times reported on August 3.

Writing in Inside HigherEd, Terry Hartle, the senior vice president of global affairs at the American Council on Education, argued for the creation of student contact tracing corps, saying that there’s a “strong trend towards idealism in America’s youth” that may drive students to take such positions.

“We're not just training people to do this work for the short term.”

Reid has trained 7,000 contact tracers of all ages. Given that experience, he says we will “inevitably” have to train early-career public health graduates to help manage these teams. He’d like to see those people become conduits of Covid-19 institutional knowledge that stay on in the workforce after the pandemic ends. Contact tracing may go on to shape the rest of their careers.

His “loftiest vision” for these people is that they don’t retire their contact tracer skills once the pandemic is over. Maybe they might transition to other jobs in public health that make sure we can contain, or stop, the next pandemic.

“We're not just training people to do this work for the short term,” Reid says.

First, they have to make it through the current wave, and perhaps the next, of the coronavirus both physically and emotionally. Even if it takes pep talks from Anthony Fauci to make it happen, Reid is prepared to make sure the contact tracers get the boosts they need to keep going.

“Having somebody like Tony Fauci come in and tell them 'you're doing a great job,' and that this has meaning and is important, is particularly essential,” he says.