The man’s voice on the phone reminded Jessica Jaramillo of her grandfather. Jaramillo — a Latinx librarian in San Francisco who was redeployed as a COVID-19 contact tracer — informed the man in Spanish that he may have been exposed to the virus. The man, who is in his 70s, would need to quarantine at home for his own health and to protect his family and the community. “I just got this job yesterday,” he protested, insisting that he felt fine. “I need money to pay rent. Also, I have a son back home — not here — who has COVID-19 and is not doing well. I need to send money to help him.”

So Jaramillo changed tactics, aware that the need to pay for rent and care for family would take precedence over precaution. She arranged a supply of masks, provided advice for keeping others safe in the common areas of his single-room occupancy housing, and enrolled him in a text-messaging service to check on his health.

“We can’t make people choose to quarantine,” Jaramillo told Rachael Allen in the Lily. “At the end of the day, people have difficult choices. You have to trust them to make the best decisions that they can for themselves.”

Jaramillo’s phone call typifies the difficult work being done by some 37,000 contact tracers across the country. Contact tracing is a public health tool used to identify and track down people who come in contact with an infected person. With COVID-19, contact tracers try to get potentially exposed people to voluntarily quarantine for two weeks to slow the spread of the virus.

Contact tracers must gain the trust of whomever they call — no easy feat in light of the history of racism in health care that has fed mistrust of medicine and public health, fears of deportation among undocumented people living in mixed immigration status households, and the viral spread of coronavirus misinformation.

Contact tracers aren’t limited to the tracing part of the job. Their roles are “part disease detective, part social work[er], part therapist,” Emily Gurley, PhD, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, told ProPublica’s Caroline Chen.

Bridging the Cultural Gap

In California, the most culturally diverse state in the country, the contact tracing workforce must also bridge cultural and linguistic divides. The state has struggled to hire enough bilingual contact tracers, Fiona Kelliher reported in the Mercury News.

In May, Santa Clara County, anticipating the need for bilingual contact tracers who could work with the substantial Latinx and Vietnamese populations, requested from the state 150 Spanish speakers and 50 people fluent in Vietnamese. Although the state sent contract tracers, none were bilingual, which underscores the challenges that counties and the state have faced in hiring culturally appropriate contact tracers.

Now Santa Clara has about 900 contact tracers, 6% of whom are bilingual Spanish speakers. However, in Santa Clara, Latinx account for 55% of coronavirus cases and 26% of deaths, while Asians account for 10% of coronavirus cases and 36% of deaths.

“Language competency is the bare minimum, frankly, and the fact that we can’t get to the bare minimum is extraordinary,” UCSF epidemiologist Kirsten Bibbins-Domingo, PhD, MD, MAS, told Kelliher. “It’s a fundamental feature of what is challenging in California right now in terms of controlling the pandemic.”

Community organizations like Latino Health Access in Santa Ana are helping fill the gaps in the state’s contact tracing workforce. Latinx make up 76% of the city’s population. The COVID-19 death rate in Santa Ana is 46 per 100,000 people — more than double that of Orange County.

Orange County “has a very affluent community and a very poor community that works for the affluent community,” America Bracho, MD, MPH, executive director of Latino Health Access, told the Washington Post. When the coronavirus reached the county, residents of wealthier communities were largely able to work from home and order groceries and other necessities to be delivered to their doorsteps. But residents of working-class communities like Santa Ana don’t have access to the same resources.

Latino Health Access recognized the needs of the local Latinx community and quickly implemented a strategy to identify those who were sick and help them isolate. The organization hosted drive-through testing clinics, delivered food to people who needed to stay at home, and mobilized its team of promotores — Spanish-speaking community health workers — to run a bilingual call center for the community’s COVID-19 questions. While the promotores are not hired or paid as contact tracers, they play an important role in minimizing transmission of the coronavirus. “We are telling people, ‘We have your back,’” Bracho said.

CHW/Ps Go “Beyond Tracing”

Community health workers and promotores (CHW/Ps) are “essential components of a contact tracing strategy because of their relationships with both individuals and health care systems in the community, their understanding of community culture, and their knowledge of social supports needed to help people through this pandemic,” according to a report by the consumer health advocacy organization Families USA (PDF).

As trusted members of their communities, CHW/Ps are particularly well-suited to the “beyond tracing” aspects of the contract tracer’s job. (Learn about the vital role CHW/Ps have long played in community health and well-being.)

Take, for example, the state of Massachusetts, whose contact-tracing program is run by the nonprofit Partners In Health. The organization insisted that “tracers must come from the hardest-hit communities and be able to speak Spanish, Haitian Creole, or whatever language the communities do,” Jennifer Steinhauer and Abby Goodnough reported in the New York Times. The state also had to commit enough money for tracers to provide needed resources to people in self-quarantine.

“We ask: Do you need food? Infant formula? Diapers? Cab fare? Unemployment insurance? And we help them get it,” said Joia Mukherjee, MD, MPH, chief medical officer for Partners In Health. “That way people feel it’s care, not surveillance.”

A similar effort is underway in California. On August 10, Governor Gavin Newsom announced a new initiative to provide resources and services for those needing to isolate. A coalition of private and philanthropic entities (including CHCF) committed $81.8 million to build up the state’s culturally and linguistically competent contact-tracing workforce, including CHW/Ps, and pay for care resources like food assistance and delivery, support for rent payments, and child care.

These efforts will be crucial for mitigating the spread of the coronavirus among the state’s agricultural workers, who often work and live in conditions that make it nearly impossible to practice physical distancing. Given the large population of migrant workers in California, a new report from the Center for Health Care Strategies emphasizes “a need for multilingual, community-based individuals to serve as CHW/Ps who understand the needs and priorities of those they serve and who can connect them to necessary resources in a culturally responsive way.”

Public Health Departments Maxed Out

So far, only Alaska, Massachusetts, Montana, New York, Oregon, Vermont, West Virginia, and Washington, DC, have enough contact tracers to investigate their current burden of recent cases, according to an NPR analysis. California has approximately 15 contact tracers per 100,000 residents — about half the state’s estimated need.

It’s difficult to piece together a contact-tracing workforce in the middle of a public health emergency, with underfunded and understaffed local public health departments maxed out after five months of pandemic response. That’s why a growing number of health planners and advocates propose hiring CHW/Ps to help. “Stepped-up contact tracing efforts aimed at identifying and counseling those who may have been exposed to COVID-19 may provide a way to hire community health workers,” independent journalist Rob Waters wrote in Health Affairs.

“I think community health workers in the COVID-19 era have the potential for being like the Civilian Conservation Corps of the Great Depression,” Asaf Bitton, MD, MPH, executive director of Ariadne Labs, told Waters. “We could pay huge numbers of people who will be out of work to serve their community; get trained in a set of skills, both inside and outside of health care; produce better health; and offer a massive economic, social, and medical benefit.”

Shewry Joins CDPH

Sandra Shewry, MPH, MSW, vice president of External Engagement for CHCF, has been named acting director of the California Department of Public Health by Governor Newsom. Please join us in wishing her well in this interim role!

What is the state of contact tracing in your community? Tweet at me with #EssentialCoverage or email me.

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

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