LOS ANGELES — Radhika Kumar goes to work every morning hoping to save lives. As a contact tracer for Los Angeles County, her job, at least on paper, entails phoning people who have tested positive for the coronavirus, along with others they may have exposed, and providing them with guidance on how to isolate so as not to infect others. If that sounds easy, it is not.
To convince people to cooperate, she has to get them to trust her. She has to convince them that they might be infected, even if they have no symptoms. “Oh yes,” she’ll say, “I’ve been hearing that a lot.” She has to let people curse at her and hang up, then she has to call them back the very next day. And if she wants them to heed her advice, she has to listen, really listen, to how scared they are that if they stay home from their jobs, they might not be able to feed their families.
“Sometimes it can really get to you,” said Ms. Kumar. “The other day I had one young lady, and she was screaming on the phone, ‘You don’t understand — I have three kids. I have to go to work.’” She went on. “I kept calling back and calling back. I’m very relentless like that. I thought about it all night — what am I going to do? I called her again first thing in the morning, and I was so relieved when she picked up.”
Even as officials at the Centers for Disease Control and Prevention continue to tout contact tracing’s effectiveness, and state and local health agencies across the nation deploy new armies of tracers, tracking down all the people with the coronavirus is proving to be a Sisyphean task.
One of the key reasons, as Ms. Kumar and many other tracers are finding out, is fear.
Lulled by the state’s early success in flattening the curve, officials in California, which now has more confirmed cases than any other state, failed not only to anticipate the outbreak’s more recent trajectory, but also people’s reluctance to cooperate with the government’s tracing effort. Some simply can’t be bothered, but more often people decline to participate because they are worried about wage loss, deportation or stigmatization.
Taken together, those factors have created a snowball effect that has overwhelmed tracers’ ability to reach people before it is too late.
In Los Angeles County, tracers were assigned 13,766 cases over the week ending July 28. But more than a third of the calls to people who tested positive went unanswered, and more than half of those who did pick up refused to provide at least one close contact.
“People are reluctant because they are scared,” said Ms. Kumar, a 55-year-old mother of two. “I’ve even had one person ask, ‘Are you F.B.I.?’ I said no, but they were like, ‘Well you could be.’ I just kept saying, ‘I could be, but I am not!’”
It wasn’t supposed to be this way. This spring, after California public health officials were forced to abandon widespread tracing in the face of an overwhelming onslaught of cases, Gov. Gavin Newsom regrouped and launched the most ambitious program in the nation to keep track of infected people and those they may have exposed.
The effort, called California Connected, has cost upward of $30 million. It includes a new online academy run by the University of California to train county and state employees as disease investigators, and a public education campaign to reassure Californians that any information tracers gather is confidential.
The state met an ambitious timetable of enrolling 10,000 trainees by early July. But while public health officials credit the manpower surge with helping to contain the pandemic at the margins, the program has been no panacea.
To be effective, contact tracing must take place promptly. The sooner public health workers reach a person who has tested positive, the sooner they can explain how to isolate and, as importantly, get a list of the person’s close contacts so they can advise them to quarantine at home.
When the state decided it needed 10,000 new tracers to accomplish that goal, it based the decision on an estimate that by this point in the summer, California would be seeing about 3,600 new cases a day, said Dr. Mark Ghaly, who as the secretary of the Department of Health and Human Services oversees California’s virus response.
But that estimate failed to account for the explosion of cases that followed the easing of the state’s stay-at-home order. On the day earlier this month that California surpassed New York to top the nation in total confirmed cases, the state recorded a record 12,807 cases, or more than three times the earlier estimate.
The spike has also caused long delays at testing labs, meaning investigations triggered by positive results are taking longer to initiate.
Dr. Ghaly believes that California has enough tracers, at least for now. But at the county level, where daily call logs are getting longer and longer, officials say initial contact is now taking up to a week in some places, if it happens at all.
Chris Finnie, who at 70 is in a high-risk category, teaches an adult ceramics class in central California that has been on hold since March. Last month, in line with reopening guidelines, she decided to offer a makeup class. She moved the pottery wheels outside, put out hand sanitizer and sprayed down contact points before and after the class.
Two students came. Two days later, one of them emailed her to say she had tested positive. That result should have been conveyed by the lab to county health officials. But in an interview one week after the class, Ms. Finney said her student had yet to be contacted by the Santa Cruz County Health Department, and as a result, neither had she. “It’s very confusing,” Ms. Finney said.
In Los Angeles County, where the number of tracers has gone from 200 to 2,600, Ms. Kumar and her colleagues are better equipped to keep up; once they are notified of a case, they are able to attempt to follow-up within a day more than 94 percent of the time.
But they are grappling with a more basic challenge: Getting people to answer the phone. Response rates vary, but in Los Angeles, they are so worrisomely low that the county is now offering $20 gift cards to people who complete an interview. Each day, tracers tackle a log of somewhere around 3,000 to 4,000 calls, said Dr. Jeffrey Gunzenhauser, the chief medical officer for the Los Angeles County Public Health Department.
On an average day, they might complete roughly half, meaning 1,500 to 2,000 roll into the next day, along with whatever new cases pop up. The county attempts to contact a person on three consecutive days before labeling the case a refusal.
Over the most recent seven-day period for which data was available, less than 60 percent of people who tested positive for the virus agreed to an interview.
Of those, only 40 percent were willing to provide at least one close contact. Of those close contacts, less than 64 percent picked up the phone and participated. And it remains an open question as to what percentage of people that are reached actually follow the guidance offered, which is the entire point of the program — but which officials have no ready way to track.
The Coronavirus Outbreak ›
Frequently Asked Questions
Updated August 6, 2020
Why are bars linked to outbreaks?
- Think about a bar. Alcohol is flowing. It can be loud, but it’s definitely intimate, and you often need to lean in close to hear your friend. And strangers have way, way fewer reservations about coming up to people in a bar. That’s sort of the point of a bar. Feeling good and close to strangers. It’s no surprise, then, that bars have been linked to outbreaks in several states. Louisiana health officials have tied at least 100 coronavirus cases to bars in the Tigerland nightlife district in Baton Rouge. Minnesota has traced 328 recent cases to bars across the state. In Idaho, health officials shut down bars in Ada County after reporting clusters of infections among young adults who had visited several bars in downtown Boise. Governors in California, Texas and Arizona, where coronavirus cases are soaring, have ordered hundreds of newly reopened bars to shut down. Less than two weeks after Colorado’s bars reopened at limited capacity, Gov. Jared Polis ordered them to close.
I have antibodies. Am I now immune?
- As of right now, that seems likely, for at least several months. There have been frightening accounts of people suffering what seems to be a second bout of Covid-19. But experts say these patients may have a drawn-out course of infection, with the virus taking a slow toll weeks to months after initial exposure. People infected with the coronavirus typically produce immune molecules called antibodies, which are protective proteins made in response to an infection. These antibodies may last in the body only two to three months, which may seem worrisome, but that’s perfectly normal after an acute infection subsides, said Dr. Michael Mina, an immunologist at Harvard University. It may be possible to get the coronavirus again, but it’s highly unlikely that it would be possible in a short window of time from initial infection or make people sicker the second time.
I’m a small-business owner. Can I get relief?
- The stimulus bills enacted in March offer help for the millions of American small businesses. Those eligible for aid are businesses and nonprofit organizations with fewer than 500 workers, including sole proprietorships, independent contractors and freelancers. Some larger companies in some industries are also eligible. The help being offered, which is being managed by the Small Business Administration, includes the Paycheck Protection Program and the Economic Injury Disaster Loan program. But lots of folks have not yet seen payouts. Even those who have received help are confused: The rules are draconian, and some are stuck sitting on money they don’t know how to use. Many small-business owners are getting less than they expected or not hearing anything at all.
What are my rights if I am worried about going back to work?
- Employers have to provide a safe workplace with policies that protect everyone equally. And if one of your co-workers tests positive for the coronavirus, the C.D.C. has said that employers should tell their employees — without giving you the sick employee’s name — that they may have been exposed to the virus.
What is school going to look like in September?
- It is unlikely that many schools will return to a normal schedule this fall, requiring the grind of online learning, makeshift child care and stunted workdays to continue. California’s two largest public school districts — Los Angeles and San Diego — said on July 13, that instruction will be remote-only in the fall, citing concerns that surging coronavirus infections in their areas pose too dire a risk for students and teachers. Together, the two districts enroll some 825,000 students. They are the largest in the country so far to abandon plans for even a partial physical return to classrooms when they reopen in August. For other districts, the solution won’t be an all-or-nothing approach. Many systems, including the nation’s largest, New York City, are devising hybrid plans that involve spending some days in classrooms and other days online. There’s no national policy on this yet, so check with your municipal school system regularly to see what is happening in your community.
“We worry the most that we make all these calls, but they don’t translate into isolation or quarantine,” Dr. Ghaly said. “So we are spending more and more time trying to make the calls educational — it’s sort of a choice between can we do a high volume of calls versus can we make impactful and effective calls.”
That is where people like Ms. Kumar come in. Born in Malaysia, she came to the United States more than three decades ago. After raising her children, she decided to go back to school in 2011; public health appealed to her, she said, as a way to give back to her adopted country. Now, it’s personal — one of her close friends, a nurse, is battling the virus.
She spends anywhere from 20 to 45 minutes on a call, acting as an epidemiological investigator, educator and social worker wrapped in one.
Contact tracing is not just a matter of reading from a script, though every tracer is given one. It is not just calculating the number of days a person must self-isolate, or learning certain tricks of the trade, like the fact that it is better to call older people earlier in the morning because the younger ones tend to sleep in. Ultimately it involves something much harder to teach.
“How do I convey my message and be empathetic, when I cannot even see their expression when they cry,” Ms. Kumar said she asks herself. “It’s not just an interview. It’s a conversation. I say, ‘I am here to help, let’s figure this out together.’”
One recent call involved a young mother who was positive, expecting twins and speaking from a room with her two other young children just on the other side of the door. What do the babies feel like when they move? Ms. Kumar asked, hoping to build a connection before she gently asking the mother what she was doing to isolate.
The woman told her that whenever she leaves the room, she wears gloves and a mask, but then her voice caught. “It’s hard to hug my kids with gloves on,” Ms. Kumar recalled her saying.
She told the woman she understood, but that it was important to keep her distance.
Some people she calls are worried because their immigration papers aren’t in order. “Yup, I don’t care about that, I care that you are safe and your family is safe,” she’ll respond, before assuring them that Los Angeles does not share information with federal immigration authorities.
One restaurant worker she recently contacted didn’t want to give his place of work, for fear managers would blame him for having to quarantine themselves. Other times, people will tell her they are self-isolating when she can hear that they are out and about.
She said the best approach is to educate rather than confront. She explains why it is important that co-workers be notified, and that the county can do that without ever mentioning the infected person’s name. Sometimes it works, but not always; one older lady adamantly refused to name the family members helping to care for her, insisting they were “doing the right thing” and “cleaning everything.”
On a recent Friday, Ms. Kumar managed to speak with 10 of the 14 people on her list. In most instances, it took multiple attempts. One person cited a “work call” and told her to try again in the morning.
But she keeps at it. For every case she finds and isolates, she figures she is preventing at least some spread. That is all she can hope to do, she said, until there is vaccine.
“We are making a difference — I know we are,” Ms. Kumar said as she prepared for another day of calls, a long list of new cases in front of her.