[Studies of past emerging disease epidemics have taught us that
testing alone will not prevent new outbreaks. To re-open the economy
we must undertake the most massive effort to trace and isolate new
infections in history. ] [[link removed]]

TO RE-OPEN SAFELY WE NEED A “HEALTH FORCE” OF DISEASE DETECTIVES
 
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Sandy Smith-Nonini, PhD
May 12, 2020
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_ Studies of past emerging disease epidemics have taught us that
testing alone will not prevent new outbreaks. To re-open the economy
we must undertake the most massive effort to trace and isolate new
infections in history. _

, Photo Illustration: Hitomi Kuromoto

 

Conservative governors are now openly at odds with epidemiologists as
plans move ahead for more than half the states to loosen social
distancing and permit many businesses to re-open this month despite
none of them meeting White House Coronavirus Taskforce guidelines. 
 

Unlike re-openings in China, Hong Kong and South Korea where new cases
fell rapidly after aggressive containment efforts, the United States,
with nearly 1.4 million cases and over 81,000 COVID-19 deaths (as of
May 11), must follow a different model.  

Many critics blame the Trump Administration’s laggard scale-up of
testing for the dilemma.  But studies of past emerging disease
epidemics have taught us that  testing alone will not prevent new
outbreaks. To re-open the economy we must undertake the most massive
effort to trace and isolate new infections in history.

Ironically, the states moving most rapidly to restore commerce – eg.
Georgia, Texas, and Florida – not only have regions with high case
loads, but also inadequate public health workers to contain new
outbreaks, according to a study  by Politico. In the Midwest, despite
high case loads per capita in Iowa and Nebraska, officials are jumping
ahead of federal criteria calling for two weeks of falling cases
before relaxing stay-at-home rules. Robert Redfield,  director of the
Centers for Disease Control and Prevention (CDC), warns that
re-opening requires not only ramped up testing, but “very
aggressive” contact tracing of new cases. Such disease tracking,
together with testing, was critical to controlling spread of the virus
in South Korea, New Zealand,  Germany and China.

An April 27 letter released by former public health officials,
including Andy Slavitt, who ran Medicare and Medicaid in the Obama
administration, and Scott Gottlieb, a former Food and Drug
Administration chief under President Trump, estimated 180,000 contact
tracers are needed to re-open the economy.  Tom Frieden, who directed
the CDC from 2009 to 2017, extrapolated from experiences in Asia to
estimate that up to 300,000 such workers may be needed across the
country.  At present local health departments and the CDC have only
about 2,200 professional “disease detectives,” although other
health staff often assist during a contagious outbreak.
Until early May, federal officials and the media have tended to ignore
contact tracing despite the critical role it has played in every
infectious disease outbreak. The labor-intensive nature of the task is
probably why. Our chronically underfunded, and now overwhelmed, public
health departments have no capacity for such a massive scale up
without significant new funding.

A recent NPR survey and follow-up report on 44 state health
departments turned up a total count of 11,142 workers trained in
contact tracing. As a point of  contrast, at the height of China’s
viral crisis it took 9,000 contact tracers in Wuhan alone to contain
the outbreak. Officials in state health departments surveyed described
a variety of plans to expand capacity, some relying on volunteers,
with the goal of scaling up to 66,197. Most will need federal aid for
the new hires.  
Unfortunately, there is no federal health workforce or emergency fund
up to the task. The closest we have to a US rapid response team might
be the Medical Reserve Corps (MRC), which matches over 175,000
volunteers with public health and medical assistance needs across the
country. Thousands of MRC volunteers are now deployed in call centers
or administering tests during the coronavirus crisis.  Some may be
trained as contact tracers in coming months.
We also entered into the COVID-19 crisis with a shortage of nurses and
primary care doctors. The Chinese government sent 42,000 health
workers to the Wuhan from other parts of the country. Despite the
likelihood that many new hot spots will crop up here as we re-open,
the United States lacks a coherent mobile medical corps of
professionals who can be deployed rapidly. Given the perpetual
shortages of physicians in US rural areas, another program that
deserves to be scaled up is the underfunded “National Health Service
Corps” which ties medical school loan forgiveness to commitments by
new doctors to practice for two years in underserved areas.

Our urgent need to scale up infectious disease control is not unlike
the impetus for the Green New Deal (GND) jobs & infrastructure
proposal to support a just energy/climate transition. Both ideas draw
inspiration from President Franklin D. Roosevelt’s response to mass
unemployment in the Great Depression by creating the Works Progress
Administration which hired millions of unemployed people over an
eight-year period for public works projects.

Clearly the need to address the climate crisis remains urgent, but
first we have to get out of the house safely. Jeremy Brecher, of the
Institute for Policy Studies, has called for such an emergency GND
that includes health.  Such a new health corps could offer a win-win
solution to our two acute (and simultaneous) dilemmas:  record levels
of unemployment and a vital need for more feet-on-the-ground to reduce
our viral case load.

At present, many political observers predict that after the pandemic,
citizens will demand more investment in health care and disease
surveillance. Thus, a plan to strengthen health staffing – including
new professional and community health workers -- could address future
needs as well as our current emergency. Besides containing new
infections and providing vital paychecks to our unemployed, like other
“essential” workers, new health workers would spend their funds
into the economy boosting demand for goods and services.

Dr. Frieden argued in early May that lockdowns, while effective at
stopping spread, are blunt tools that cause unemployment and
bankruptcies. Instead, he said, “we have a sharper tool, (a
strategy) to stop chains of transmission by widespread testing,
isolation of cases, contact tracing and quarantine of contacts.”

Frieden, who now directs the non-profit Resolve to Save Lives, gained
extensive experience overseeing responses to the H1N1 influenza, Ebola
and Zika epidemics while running the CDC. But the importance of
contact tracers was brought home to him many years earlier in New York
City.  I did post-doctoral research in 1999 comparing two epidemics
of resurgent multi-drug-resistant tuberculosis (MDR-TB) – one in New
York City and one in Lima, Peru. I learned that Frieden, while working
in the CDC’s Epidemic Intelligence Service in 1991, helped
demonstrate that MDR-TB was widespread in many poor neighborhoods of
New York City, a finding that spurred the mayor to replace city health
officials who had ignored mounting signs of the epidemic.

Frieden was appointed to lead the city’s tuberculosis division and
later credited for innovative policies thar brought the deadly
outbreak under control. One key initiative was the hiring and training
of community health workers (who did not have professional degrees) to
do outreach, track cases and administer doses of anti-TB drugs,
effectively cutting the chain of contagion and drug-resistance.

Community health workers were also the key to controlling MDR-TB in
Peru. TB drug resistance was first identified in a barrio of Lima in
the late 1990s by the Boston-based non-profit Partners in Health
(PIH). Drs. Paul Farmer and Jim Yong Kim, who directed PIH, built a
program at an urban clinic in Lima to address the deadly outbreak
using a similar strategy of outreach and treatment with lay workers
doing home visits and social programming with patients. In both the
New York and Lima epidemics, a training staple for successful
community outreach was cultural sensitivity and a willingness to
establish relationships and trust with patients and their families.
PIH’s Peru work helped established a model for treating MDR-TB
outbreaks in low-income countries.

PIH is now applying that experience to COVID-19 in Massachusetts where
the health department recently contracted with PIH to hire 1,000
fulltime community health workers as half of a 2,000 person contingent
who will do contact tracing statewide. Another model may be California
which has invested in a well-designed  disease tracking system, and
now aims to combine hired staff and volunteers to ramp up to 10,000
contact tracers.

Since April 1 new US cases per day have exceeded 20,000 on every day
except one, and have ranged as high as 38,000. Epidemic models predict
the infection will continue to spread across the country in the months
ahead, producing not hundreds of thousands, but millions of new
infections, especially in places where social distancing is lax. 
Many states project using new electronic tracing systems for COVID-19
exposure which have been heavily hyped by tech companies, such as
Google and Apple. But even if the serious privacy concerns raised by
these apps are resolved, such systems will only be an aid, not a
replacement for humans who follow-up with contacts exposed to the
virus.

The work of a contact tracer, ideally hired from the same area where
he or she would serve, starts with interviewing infected patients and
following leads to find people that person was recently in contact
with. These workers then help arrange testing for new contacts, advise
them on self-isolation, and assist those who become sick with
treatment and access to humane quarantine options like hotel rooms or
other facilities for patients in crowded households so as to avoid
infecting immune-compromised or elderly members. Support for patients
in quarantine would include food and daily follow-up on medical needs.
This level of support is the only way to prevent super-spreader events
– such as the widely reported outbreaks at funerals or nursing homes
that contributed to the US having a quarter of all reported cases
globally.

When locally-based and trained well, community health workers are also
the ideal outreach personnel to educate others on coronavirus
prevention and treatment, including advice on chronic problems that
contribute to high COVID-19 mortality rates in Latino and Black
families. In the long run such a workforce could help address the
long-standing shortage of primary care in the United States
--including community-based programming to assist families with
preventive health, nutrition, exercise, chronic diseases and mental
health needs.

In their public letter, Drs. Gottlieb and Slavitt called for $46
billion in national support for states to trace contacts and isolate
infected patients, with an additional $4.5 billion for quarantine
facilities, including rental of otherwise vacant hotel rooms.  While
the last Congressional stimulus package (HR 266) contained $25 billion
for state health departments, the bulk of those funds were aimed at
scaling up testing, with only a small slice likely to be spent for
tracing contacts.  

To re-open safely, the country needs a more comprehensive approach.
One promising bill, introduced by Sens. Kirsten Gillibrand (D-N.Y.)
and Michael Bennet (D-Colo.), would allocate $55 billion a year for
a new “Health Force” – training and hiring  hundreds of
thousands of new public health workers to do testing, contact tracing
and eventually vaccinating the population. The Senators even cite
FDR’s Great Depression work program as an inspiration.

It is clear that re-opening alone will not rapidly reduce
unemployment, and federal stimulus efforts to date to keep working
people afloat are woefully inadequate. The country needs to look
beyond welfare solutions. There is much work to be done. Why not hire
the unemployed to find and stem new viral outbreaks so we can reopen
without recurring waves of deadly outbreaks?  Until we have an army
of disease detectives, the virus will continue its massive crime wave.

[Sandy Smith-Nonini, PhD, is an adjunct assistant professor of
anthropology at the University of North Carolina -Chapel Hill. She is
the author of Healing the Body Politic: El Salvador's Popular Struggle
for Health Rights from Civil War to Neoliberal Peace
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Her writings on the drug-resistant tuberculosis epidemic in Peru and
New York City can be found at
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