Elaine Thompson/AP Photo
A public-health nurse, right, checks in with a patient self-quarantined at home, at King County’s public-health department, in Seattle, February 13, 2020. Officials in several states performed intensive contact tracing in the early stages of the coronavirus outbreak.
During the past month of shelter-in-place, one of my outdoor escapes in my hometown near San Francisco has been a hike that passes a stone fire tower built in the 1930s. Probably there is one like it near you. It’s a reminder of the most popular program of the New Deal, the Civilian Conservation Corps (CCC), which employed three million young and otherwise unemployed American men to build trails, fight river erosion, and perform dozens of other civic tasks. It benefited the country and unemployed individuals simultaneously.
Today, as our country faces an epic public-health and economic crisis, we should take a page from FDR’s Depression-era playbook. We should create a Public Health Corps of newly unemployed American men and women, who instead of building fire towers and trails will be retrained in the vital work of contact tracing for the coronavirus.
Every serious plan that aims to revive the American economy and defeat COVID-19 lists contact tracing—locating people who have been in close contact with someone who has tested positive for the virus, and putting them in quarantine or under observation—as one of the key steps.
Public-health officials in several states performed such intensive tracing in the early stages of the coronavirus outbreak, until it was clear that the community spread had overwhelmed containment. But despite support for this practice among public-health leaders and across the political spectrum, we haven’t begun to muster anything close to the number of people and dollars needed to carry out this important task.
Even if we fix the scattershot pattern of testing to date, in a nation of over 330 million people many cases will slip through the cracks.
The use of contact tracing, along with massive testing, is one of the biggest reasons South Korea has led the world in containing COVID-19. It has been a big reason behind Wuhan’s apparent success in beating back the virus. Former Liberian health official Tolbert Nyenswah (a lawyer by training) assembled a contact-tracing team of some 4,000 workers, many of them educated in public health from scratch, to successfully battle the Ebola virus in Liberia. In his words, “You will never beat a virus like this one unless you get ahead of it. America must not just flatten the curve but get ahead of the curve.” Contact tracing is the key to doing this.
If we manage to do extensive testing, why do we also need contact tracing? Even if we fix the scattershot pattern of testing to date for coronavirus, in a nation of over 330 million people many cases will slip through the cracks. False negatives and positives are a feature of even the most accurate tests. More important, those who have been infected can pass on COVID-19 before they show symptoms.
Even if everyone in the country were tested today, there still would be thousands of people who have been exposed who have yet to develop the virus. If those people could be notified, they could self-isolate, rather than unintentionally infect more people. Once we reduce the number of new cases and hospitalizations to a manageable level, and before an effective vaccine is developed, contact tracing may be what enables us to return to daily life without suffering a large resurgence of infections.
The challenge of contact tracing is that it’s heavily labor-intensive. According to a report from the World Health Organization, in Wuhan alone more than 1,800 teams of epidemiologists, with a minimum of five people per team, were tracing tens of thousands of contacts a day, 1 to 5 percent of which resulted in new coronavirus cases. If just one-tenth of the current U.S. coronavirus caseload remains, or around 60,000 active cases, this would imply a need for some 300,000 workers devoted to contact tracing.
The existing public-health workforce in the U.S. numbers just over half a million under the most generous estimates. It is already stretched too thin by other demands to pursue large-scale contact tracing. The epidemiology section of the American Public Health Association estimates that the public-health system fell some quarter of a million workers short of being able to meet basic standards of preparedness even before the onset of COVID-19. Over 50,000 jobs lost during the Great Recession have not been replaced, and the ranks of public health are being reduced by retirement faster than they are being replenished with new graduates.
While the stimulus package passed last month allocates over $4 billion to the Centers for Disease Control and Prevention (CDC) and includes a relief package for states, it is far from sufficient both to rejuvenate the existing public-health infrastructure and to build sufficient capacity for contact tracing.
That’s where the Public Health Corps comes in. The government should create a dedicated program to directly hire hundreds of thousands of contact tracers, under the direction of the CDC, to do the manual labor of interviewing carriers of the virus, finding their contacts, and getting them into quarantine.
In addition to being a public-health necessity, contact tracing can serve as a temporary jobs program.
Extensive contact tracing will require what former CDC Director Thomas Frieden has called an “army” of new workers. Fortunately, most of these hires do not need to be health care experts. They can be drawn from the millions of Americans who have lost their jobs and who can be retrained to perform this new task. In addition to being a public-health necessity, contact tracing can serve as a temporary jobs program.
Several states and localities are showing that this idea can work in practice. Massachusetts Gov. Charlie Baker is collaborating with the nonprofit global health organization Partners in Health to hire 1,000 contact tracers who will work out of 36 community health centers. A project manager reports receiving ten applicants for each available spot. Under Mayor London Breed, San Francisco expects to have 250 contact tracers trained by the beginning of May. The infectious-disease expert who is heading up the city’s pilot program envisions the possibility of tens of thousands of workers and volunteers eventually signing on.
A dedicated national Public Health Corps will offer advantages that state-level programs lack. A national program can proceed with more secure funding than states, which must scramble to balance their budgets in historically unpromising times. It can match the duration of the COVID-19 crisis, while most state ventures will be time-limited. The Partners collaboration in Massachusetts, for instance, runs only through January 2021. Most important, a national corps will have the mobility and flexibility to reposition quickly when coronavirus flares up in different parts of the country. This is a key element to making contact tracing effective.
To be sure, technology also can assist with contact-tracing work. For instance, a recently announced crowdsourcing effort with cellphones launched by a partnership between Google and Apple is promising. But such initiatives rely heavily on the uncertain voluntary participation of Americans and raise thorny issues about privacy. They are likely to complement rather than replace painstaking “shoe-leather epidemiology.”
The value of a new Public Health Corps goes beyond giving skilled unemployed workers a job to help stem a crisis of unprecedented proportions. Because public health works best when it is least visible, it is chronically vulnerable to budget cuts when things seem to return to normal. Giving thousands of young Americans a firsthand look at the tools and tradecraft of public health could help create a long-term constituency for its programs and prepare us for the infectious-disease challenges of the future.
