States across the country are turning to one of the most basic practices of epidemiology to stamp out the coronavirus, deploying contact tracers to identify and inform anyone who has come into contact with the virus that they are at risk.
Every day, thousands of tracers and case investigators head to the new front line in the war against the coronavirus, legions armed with iPhones, databases and carefully worded scripts meant to both educate and reassure. They deliver bad news to those they call, and they bear witness to the suffering their communities endure.
These are their stories.
'The bearer of bad news'
Kelsey Green spends her day in a cubicle at the Carroll County Health Department, northwest of Baltimore. As a contact tracer, she has to convince those she calls that the number they don't recognize is not a spam call.
For those who pick up, Green usually has bad news: She tells them they have been in contact with someone who has the coronavirus.
Their reactions span the gamut of human emotion. Some calmly acknowledge confirmation of what they already suspected. Others are fearful. Some are angry, and Green becomes their target. Others deny that the coronavirus is even a threat.
"It's not a fun job at times. A lot of people don't want to hear it, but when they do hear it, they're receptive and thankful," Green said in a recent interview. "It seems a little intrusive, but it makes me so happy if someone answers and I'm able to tell them, ‘Hey, you've been in contact with someone who's tested positive. Can you quarantine?’ Mission accomplished, we're good to go, because that person knows."
Green said she has been struck by the variety of symptoms that can manifest in a confirmed case. She recalled one person who tested positive after their spouse sent them to the doctor. The spouse had recoiled from their child's rank diaper; the person who tested positive couldn't smell a thing.
Others have been "so physically ill that they can't speak," Green said. One person who tested positive asked how their spouse was doing in the hospital. Another grew angry after learning they were infected, news that hit three days after their own spouse had died from something other than the coronavirus. A third broke down and sobbed when they learned they had been exposed at a funeral.
"I'm the bearer of bad news, I understand that. But I want to make sure another funeral does not happen," Green said.
The Carroll County Health Department tries to reach contacts within 24 hours of learning they may have been exposed. An investigator conducts a comprehensive interview with anyone who has tested positive, walking them slowly through the last 48 hours, learning the names of those with whom they have come into close contact. Those names are turned over to Green's team, who calls and delivers the bad news.
For privacy reasons, they cannot share the full story with the person on the other end of the line.
"A lot of contacts have no idea where they got this from, who they got this from, because we're not allowed to say who the index case is," Green said.
The calls often last an hour or more, depending on how much the contact has to share or how they react emotionally. At times, Green has felt like a psychiatrist, or even a shoulder to cry on.
At the end of the call, her team sends the contacts a series of documents — recommendations on how to quarantine, agreements that they will abide by isolation rules, information about symptoms and what to do if a contact becomes a case.
Green said the calls can be taxing, emotionally exhausting, incredibly rewarding when she realizes her message has gotten through. And while many people she calls are afraid at first, Green says the work has helped her find a place in her community.
"I felt like I had a purpose," she said. "I felt like I had a reason to exist and be here to help other people exist and be here."
Just out of college in the ’90s, Kim Steele-Peter took a job with the Centers for Disease Control and Prevention, where she helped battle sexually transmitted diseases and HIV in Florida, Louisiana and Nevada.
Now, she hunts for viral hepatitis in Pierce County, Wash., about half an hour south of Seattle. She had just returned from vacation when the first coronavirus cases erupted all around her.
"At our peak, we were having about 50 to 80 index cases a day. No New York, but we're much smaller," Steele-Peter said on a recent day off.
The Tacoma-Pierce County Health Department is down to tracking about 10 cases a day.
Her department is practicing what they preach, staggering staff to ensure social distancing — and to be able to operate seven days a week — wearing face masks at work, staying six feet apart.
Each day starts with scrutinizing the list of cases from the day before, scrubbing the data to make sure they are neither undercounting nor double counting those who are infected. The risk of bad data is significant: Laboratories and health care providers all send in information in different ways, and sometimes multiple times for the same patient.
Sometimes, the person on the phone from the health department is the first to tell someone their test has come back from the lab.
"A lot of times people don't know that they have tested positive for COVID-19. We're the first people to tell them," she said.
Those who test positive are often concerned about what is to come — not just how the disease will manifest in their bodies, but how they will cope with work, with bills that need to be paid, with the basics of grocery shopping. Steele-Peter's team has those all taken care of.
"We talk to them about whatever wraparound services they might need. Is there somebody who can get out of the house and get them food, get them supplies? How can we problem-solve to get them services they need so they can stay home," she said. "We're trying to make it easier to do the right thing."
Tacoma is an increasingly diverse city, and Steele-Peter said the virus is hitting black, Hispanic, Native American and Pacific Islander families the hardest. Some index cases worry that if they list their undocumented family members as contacts, Immigration and Customs Enforcement will show up at their door. Steele-Peter's team has to reassure them they do not report individual names of contacts.
Months into the outbreak, what felt like a sprint is now becoming a marathon. Staffers are given regular schedules so they can settle into something approaching a normal routine. Their overtime is generous.
"We can't treat our staff as disposable. They are not disposable. They are well-trained," she said.
But she worries about the resources being dedicated to the essential and immediate fight, resources that are no longer being spent on other public health crises — like the hepatitis she is more used to tracing.
"What we do in public health is quiet, it is behind the scenes. This is not. COVID-19 is front and center," she said. "But what that means is that it's taking people from all of that quiet work that keeps people safe on a day-to-day basis, and that every time taxes are cut or money is reassigned to some other function out of public health, we get leaner, we figure out how to streamline.
"But when these big events hit, that means that we have to pull resources from already strapped programs, or that we lose programs entirely."
No chance to grieve
When someone in Carroll County contracts the coronavirus, the county epidemiologist downloads the patient's information to deliver to Maria Carr. As the county's community COVID-19 coordinator, Carr assigns the case to an investigator who will interview that index case to identify their contacts.
All day, the cases trickle in. Then, at quitting time, a rush of new paper hits her desk.
Carr's investigators start at the beginning: When did the index patient start experiencing symptoms? What is their living situation? With whom did they come into contact in the 48 hours before they got sick? Most of the time, because of lockdown orders, their only contacts are immediate family members, Carr said.
But other times, economic reality means health takes a back seat — especially in a community with substantial populations of both blue-collar workers and undocumented immigrants, many of whom live in close proximity to lots of other people.
"Some people's stories change, and some people are scared. Also, some people economically feel like they have to work, they don't have a safety net," Carr said. "They don't have the luxury of getting the unemployment check or the stimulus check."
Late in the day, if she cannot bear to hand one of her investigators yet another case, Carr will make the calls herself. One night, she called a woman who had tested positive, fallen severely ill and recovered. The woman flipped the script and began grilling Carr.
Why are you still at the office, the woman asked. You need to be home with your family. "She kind of started interviewing me," Carr said.
"It really hit me that we do throw our heart and soul into this job," Carr said. She hung up the phone and cried. "It does really take a toll on you some days."
The toll hits hardest when she has to call a family who has already paid the highest price. She realizes then that the enforced social distancing requirements that have saved so many from becoming ill have robbed others of their chance to mourn.
"Because of the way people are limited in their grief process, either funerals or hugging, that has really been hard," she said. "That lack of being able to have proper closure, the way we normally do where we have lots of people coming to hug us and comfort us, that has been one of the hardest things I've had dealing with this."
'How am I going to get paid?'
As Southern California prepared to reopen, a teenager scored his first job cleaning a park. Three days later, the boy's mother got sick, contracting the virus during her first week back at work after two months of shutdown.
When Rachel called, the boy was frustrated. I just got this job, he said. If I have to stay home for 14 days of quarantine, will it be there when I go back?
Rachel, a contact tracer in Southern California who asked that her last name not be used, landed a job as a contact tracer in early May. After about 25 hours of training, and a month on the job, she is overseeing about 20 cases. Through their eyes, she has seen the devastation the virus causes for hourly workers and those who do not have regular work. They know the virus is stalking them, infecting their friends and neighbors.
"It's the working-class people where I live that are badly affected," Rachel said. "They are not unfamiliar, especially the Hispanic community that I've talked to."
Three-quarters of the calls Rachel makes are to Hispanic households. In most cases, it is the working-age parents who are sick — and who then pose a risk both to their children and to their elderly parents who might be living under the same roof.
Some cases haunt her. An older man knew he was a contact — his father had already died of the disease. He had not been able to pick up his father's ashes. His brother was in an intensive care unit. The man wept.
One of her index cases was a young mother, still nursing her infant. Her husband told Rachel he was having trouble keeping their other children, toddlers, away from their mother. And money was getting tight: The father had to stay home for 10 days while his wife recuperated, then for another 14 days to make sure he too did not fall ill. The man's employer said a letter ordering him quarantined, issued on county letterhead, was insufficient.
"That's 24 days out of work, at a minimum," Rachel said. "It just feels really unfair because we don't have the social supports in this country to let people isolate and quarantine if they're hourly workers."