The Most American COVID-19 Failure Yet

Contact tracing works almost everywhere else. Why not here?

The Atlantic

With her thin eyebrows arched high on her forehead, Robyn Openshaw urged her 212,000 fans to stand up to a new menace: contact tracing. Openshaw, a widely followed health blogger who goes by “Green Smoothie Girl” on Facebook, had recently heard of a bill in Congress that would provide $100 million to mobile health clinics to help monitor the spread of COVID-19.

“Are you willing to hand over your freedom and create a health police state?” she asked her viewers, punctuating her statements with a karate chop to the air. “We will hold them accountable for the rollout of what looks an awful lot like communism.”

Openshaw is so suspicious of contact tracing that when restaurants she dines at ask her for a phone number so they can call her if someone else at the restaurant tests positive for COVID-19, she sometimes gives them a fake number, she told me later.

Her fears are ill-founded. Contact tracers recommend that infected people self-isolate, but they have no power to enforce isolation. Most countries with coronavirus outbreaks have started contact tracing, and of them, only China is Communist. But Openshaw’s outraged reaction to the concept helps explain a major problem bedeviling the American pandemic response: Contact tracing does not work as well here as it has in other rich countries.

Contact tracing, the last two-thirds of health wonks’ “test-trace-isolate” mantra, was supposed to get us out of the pandemic. It’s meant to work like this: Let’s say Aunt Sally tests positive for COVID-19. A tracer working for the local public-health department calls her and asks for her contacts—anyone she’s spent more than 15 minutes with recently—and asks her to self-isolate. Then the tracer calls those “close contacts” of Aunt Sally’s, and asks them to self-isolate too. The tracer doesn’t tell Aunt Sally’s contacts that she is the person who tested positive, only that someone they were in contact with did.

In the United States, this whole process is failing, allowing Aunt Sally to continue roaming about town, infecting others and spreading COVID-19. There is no national contact-tracing program in the U.S., and contact tracers who work for the 40 local health departments in areas with the most coronavirus cases have reached just a fraction of the patients who have tested positive, a Reuters investigation found earlier this month. In Maryland, 25 percent of those called by contact tracers don’t pick up. At one point in Miami, contact tracers were able to reach only 17 percent of the infected. In Houston, New Jersey, and California’s Inland Empire, half of the people reached by contact tracers won’t cooperate. In Philadelphia, a third of COVID-19 patients claimed they had no contacts. Philadelphia is one of the country’s most densely populated cities; it’s hard to believe that a third of the people who got sick there had no contact with their fellow Philadelphians.

Some of these numbers might not be totally accurate in the long run. For instance, some health departments might count a person who picks up a contact tracer’s second or third call, instead of the first, as a nonresponse. But even giving U.S. health departments the benefit of the doubt, response rates here are far lower than those in other countries. Less than 1 percent of sick people fail to respond to contact tracers in Iceland, Ævar Pálmi Pálmason, who leads the country’s tracing effort, told me. In New Zealand, 86 percent of people contacted by tracers respond within 48 hours. “The U.S. contact-tracing effort has been a dismal failure compared with many of its peer countries,” says Lawrence Gostin, a professor of global-health law at Georgetown University.

Contact tracers are not to blame. Tracers tend to be relatively low-paid, civic-minded workers who make calls relentlessly in an attempt to rescue the nation from a ruthless pandemic. But they’re struggling for three main reasons.

There Are Too Many Cases to Track

In July, I called up a contact tracer in Texas to see what her job was like. She was worried that she’d be fired if she talked with the press, so I won’t disclose her name here. Every day, she gets on her laptop, sets herself to “available,” and signs into Microsoft Teams. She spends all day clicking a button to see if there’s a new contact she can call.

She enjoys the work, but she had some concerns. The big one was that she felt like a public-health Sisyphus. “It’s literally too late to do contact tracing in Texas,” she said. That month, Texas had 15,000 new cases on some days. “How are you going to go back and find all those old contacts? You can’t really trace if everyone and their cousin has it.”

The countries where contact tracing has worked best set up their tracing systems before cases exploded, and as cases grew, they hired more tracers. The U.S. has not done this. In June, when states were in the throes of reopening, only seven states and Washington, D.C., met the Centers for Disease Control and Prevention’s recommendation of 30 contact tracers per 100,000 residents, according to an NPR analysis. According to the latest data from Test and Trace, an organization that grades states on their testing and tracing capabilities, only seven states are currently considered “fully prepared to test and trace.” States meet this threshold if they have a test-positivity rate of 3 percent or less, provide test results in two days or less, and employ five to 15 contact tracers per positive test. “When we started to see cases start to rise back up, hospitalizations start to increase, and then people are looking at contact tracing as this thing that’s going to stop that? Well, that’s just not what contact tracing is able to do at that point,” says Candice Chen, a health-policy professor at George Washington University.

What’s more, once a tracer asks Aunt Sally to isolate, ensuring that she actually does so can be hard, especially if she doesn’t get paid leave from work, or if she lives in a cramped apartment with lots of other people. In Iceland, the government set up a special quarantine hotel as an option for people to isolate away from their families. But few places in the U.S. have set up free hotels for isolation. Larry Wile, the medical director of a health department in southwest Michigan, told me that a nearby county had set up a COVID-19 motel, but abandoned the effort when its staff quit out of fear of getting infected. Now, Wile said, the best his tracers can do is tell infected people to stay away from their family members and wash their hands.

Testing Takes Too Long

In Iceland, Pálmason has been tested twice. Both times, he took the test at 10 a.m. and got his results by eight that evening. In the U.S., coronavirus tests are taking days to come back—largely because there are too many different kinds of tests and no national testing strategy—which further hampers contact tracers’ work. The infected are walking around for days, unwittingly infecting others. And people are naturally less likely to be able to rattle off the names of everyone they encountered five days ago, as opposed to whom they saw yesterday.

The logistical testing delays are exacerbated by quirks of the American health-care system that are making it even harder for people to get tested and quickly quarantine. Many people can’t get paid leave from work unless they provide proof of a positive COVID-19 test. So if Aunt Sally is feeling sick but her test results haven’t come back yet, she might be required to report to work or forfeit her paycheck for the day. “If that test isn’t showing up for a week, then they’ve already been exposing people for a week,” said another Texas contact tracer, who asked to remain anonymous, because she’s not authorized to speak with the press.

Many Americans Fear and Distrust Government

It’s likely that the first time many Americans heard the term contact tracing was this spring. Before that, some public-health departments were little more than two people and an old computer, having lost a quarter of their workforce through aggressive budget cuts since 2009. Because the U.S. has had such an enfeebled public-health system for so long, the public doesn’t trust public-health workers at a time when it’s crucial that they do so. When called by a department they’ve never heard of and asked for a list of all their friends, Americans could be forgiven for thinking, Who the hell are these people?

Besides Openshaw, many others got up in arms about H.R. 6666, the contact-tracing bill. Some worried that its bill number was too close to the sign of Satan. “United States Citizens, contact your neighbor, your relatives, and your friends, and warn them that contact tracing is a ploy for the worst crime against humanity: democide and population control,” a man named Demetrios Alexandros wrote on Facebook, using a term for the murder of people by the government. Someone started a petition on soon after the bill was introduced, saying it was reminiscent of life in “NAZI Germany.”

This is despite the fact that the U.S.’s methods for contact tracing aren’t especially aggressive. In South Korea, which conducted a very successful tracing operation, tracers used cellphone data and credit-card transactions to find sick people’s contacts. In the U.S., tracers rely only on phone numbers and names provided voluntarily by individuals.

Still, contract tracing depends on trust, and many Americans don’t trust the government enough to give up their contacts or follow quarantine orders. Of the 121 agencies Reuters surveyed, more than three dozen said they had been hindered by peoples’ failure to answer their phone or provide their contacts. About half of the people whom contact tracers call don’t answer the phone, because they don’t want to talk with government representatives, Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, said during a June news conference.

Examples of this distrust abound. A video with more than 325,000 views on YouTube recommends that people avoid contact tracers because they are tied to the Clinton Foundation and Bill Gates. In eastern Washington, angry locals threatened a contact tracer’s life. Some contact tracers have reported that people think they are identity thieves. (It doesn’t help that some actual scammers are posing as contact tracers.)

“I think that the politicization of contact tracing in America is definitely hampering its success,” Steve Waters, the head of Contrace, which helps connect contact tracers with health departments, told me recently. “In some areas, it’s perceived as a political act to not participate in contact tracing.”

These trust issues have become especially pronounced in the Black and Hispanic communities, two populations that have been disproportionately affected by COVID-19. Black and Hispanic people are more than twice as likely as white people to get COVID-19, and are more than four times as likely to be hospitalized with it. Several experts told me that wariness of the government in these communities has been exacerbated by the Trump administration’s public-charge rule, under which immigrants might jeopardize their green card if they accept public benefits. “If the word gets out in a community, ‘Don’t talk to the government, because we are worried the government will do bad things to us,’ then you don’t have trust,” John Auerbach, the president of Trust for America’s Health, a nonprofit that promotes public health, told me.

Some state and local officials have cleared a path for contact tracers. Few people pick up calls from numbers they don’t recognize, so in Massachusetts, the contact-tracing operation asked phone companies to display its phone number as “Massachusetts COVID team,” even for people who don’t have caller ID. That small change persuaded many more people to answer their phone, according to K. J. Seung, a global-health expert who leads the state’s tracing effort. But not all places have done this; elsewhere, some people still think contact tracers are robocallers.

People have more trust in public-health workers when local health departments, governors, and the president speak with one voice. But some officials have downplayed the virus, some have taken it seriously, and others have ignored it entirely. Other than claiming that the U.S. has gotten “good at” it, Donald Trump hasn’t said much about contact tracing. But perhaps his actions should speak louder than his words: When someone in the White House gets sick, the executive branch traces all of that person’s contacts.