When a phone call doesn’t go well in Jessica Jaramillo’s line of work, it could be a matter of life or death.
From her home in San Francisco, Jaramillo, 41, recently informed a man in his 70s that he had been in contact with someone who tested positive for covid-19. The man insisted that he felt fine. “I just got this job yesterday,” he stressed, speaking Spanish. His voice sounded so similar to Jaramillo’s own grandfather’s. She dreaded what she would have to say next.
As a librarian, Jaramillo never expected she would be drafted in the fight against the novel coronavirus. But these days, Jaramillo is digging for research in a different capacity — as a contact tracer, a practice that experts consider crucial to reopening the country.
Contact tracing consists of calling those who have tested positive for covid-19 — or those who have been in contact with them — and not only asking them to quarantine and providing them with resources to do so, but also building out the web of their contacts. As Emily Gurley, an associate scientist at Johns Hopkins Bloomberg School of Public Health, has put it, in reality a contact tracer is “part disease detective, part social work, part therapist.”
Jaramillo understands the calls she makes to San Francisco’s Latino community put people in difficult situations — undocumented immigrants hesitate to share information with her, large families living in small apartments explain they cannot self-isolate. “I think about my own family and what I would want for them,” says Jaramillo, who is Latina.
In Spanish, Jaramillo explained to the man with the voice like her grandfather’s that he needed to stay home from his new job in case he was infected for the sake of himself, his family and his community. She hoped he trusted her enough to listen.
This question of trust, moreover, is exacerbated in the communities of color and low-income neighborhoods that have been hardest hit by the virus. “There’s a lot of history and a lot of systemic racism that feeds into how receptive people are today,” says Jackie Bray, the deputy executive director of NYC Test and Trace Corps, which is run by the city’s department of health. “There are real reasons why the black community, the Hispanic community, the native community would feel very skeptical of the medical infrastructure, of the public health response.”
Today, more than 37,000 people are working as contact tracers across the United States, but experts say that more than 100,000 will be needed to combat the virus. Staffing people is not necessarily the challenge; in Massachusetts, as the New Yorker reported, getting hired as a contact tracer was more difficult than getting into Harvard. Instead, public health departments must focus on getting the right people hired, the people with the backgrounds and empathy that will enable them to earn the trust of the person on the other end of the line quickly. The end of the pandemic — and, perhaps, the outlook for trust within our communities — depends on it.
The majority of people navigating these thorny issues of trust and health right now are women. Partners in Health, a Massachusetts nonprofit that has led the way in contact tracing, shared that 83 percent of their contact tracers were women. Seventy six percent of NYC Test and Trace Corps’ contact tracers are women. Contrace Public Health Corps, an organization that helps recruit contact tracers, reported that nearly 70 percent of applicants were women, 20 percent of whom were from economically distressed communities.
“We know that women are disproportionately represented in the ‘caring’ professions and so much of the work of contact tracing gets to that notion of caring. Not just the need to establish trust and get information out of people — it’s making sure people are supported,” says Heather Ross, a clinical assistant professor at Arizona State University.
Back on the phone line, the man was quiet for a while after Jaramillo spoke. “I need money to pay rent. Also, I have a son back home — not here — who has covid-19 and is not doing well,” he told her. “I need to send money to help him.”
Jaramillo understood then that she had to change course. Nothing she could say would convince this father to abandon the needs of his sick and faraway son out of precaution that he might have the coronavirus. As if she were back behind the reference desk, Jaramillo gave the man information on staying safe in the common spaces of his single-room occupancy housing, set him up with masks for work and enrolled him in a text-messaging service that would regularly check to see how he was feeling.
“We can’t make people choose to quarantine,” Jaramillo says. “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, and hope that that aligns with what is needed in this moment.”
One thing that contact tracer Maryama Diaw knew before she started the job was that she wanted to care for her own community. Diaw, 25, lives in East Harlem, a predominantly black and Hispanic neighborhood in New York City that has been particularly affected by the virus. “I know what it’s like to grow up here and not have resources and be confused about what’s going on,” says Diaw, who is enrolled in a master of public health program at Columbia University. “As a Senegalese woman, as a black woman, as a Muslim woman, it’s important for our voices to be heard when we’re building these kinds of programs.”
Diaw just started contact tracing last week, and so far has found people to be receptive, particularly because she has been emphasizing that the calls are to provide them with everything they need to quarantine, whether food and medication delivery or a free hotel room to self-isolate. She wants them to feel the system is built for them — she thinks of her friends who need to translate for their parents or her own experience navigating the unfamiliar jump from public school to Dartmouth College. “Just knowing that you’re one of them, you’re from that neighborhood, you understand what they’re going through,” Diaw says. “You can be much more compassionate ... [particularly about the reasons why] not everyone has the privilege to social distance or isolate.”
Diaw appreciates how much New York City’s Test and Trace Corps, where she works, emphasizes community — and in some ways, it’s paying off. While the program is struggling to reach people in the first place, 86 percent of the people who did have an interview with contact tracers in the past week shared their close contacts, a success that Bray largely attributes to the fact that 50 percent of their contact tracers are from the city’s Zip codes that have been most impacted by the virus.
The program, moreover, calls for an understanding of “institutional and structural racism” in its job description for a contact tracer. When Anna Muldoon, a PhD student at Arizona State University who studies infectious-disease outbreaks and social crisis, saw that in the application, she “did a happy dance in my chair,” she says.
Muldoon and Ross, the Arizona State University professor, have studied the importance of diversity — in terms of race, gender and sexuality, immigrant status, religion and language — when it comes to building an effective contact tracing army. “Overlooking these groups can be disastrous,” they wrote in Slate, referencing a covid-19 outbreak in the LGBTQ community of Seoul, a country where being LGBTQ is so taboo that people may be particularly fearful to out themselves to a random contact tracer.
As public health departments make efforts to recruit contact tracers from the communities they will serve, the overwhelming need for them has inspired hundreds of thousands of people to seek out online training courses — even without the promise of a job. Since early May, more than 380,000 people have enrolled in and over 140,000 graduated from a free, five-hour online course offered by Gurley with Johns Hopkins Bloomberg School of Public Health.
Many of these potential contact tracers may be driven by the desire to help, or to get a job, in a time of crisis. According to the National Coalition of STD Directors, which runs another contact tracing training course, only half of participants indicated that their regular work setting was in public health or health care.
For Jan Devereux, 61, contact tracing was a way to combat the helplessness she felt reading the news at the beginning of the pandemic. From her comfortable home in Cambridge, Mass., Devereux, a former city councilor, looks out over her garden as she telephones essential workers like home health aides and grocery store employees in Brockton and Chelsea, two cities outside of Boston that the virus has deeply affected. She often needs a Spanish or Cape Verdean Portuguese translator to join the phone call. (Devereux left her contact tracing job last week for a communications position that had been in the works before the pandemic.)
Even before this moment, Devereux has had her share of awkward phone calls. When she ran for city councilor in 2015 — her first foray into politics — cold-calling would send her into tears, terrified as she was to pitch herself and ask for money. But something in Devereux’s voice convinced others, across backgrounds, she was the right person to represent them.
And in early March, while phone banking for Elizabeth Warren, Devereux found herself identifying with those who simply wanted to talk for the sake of human interaction. One time, she patiently listened to a man rehearse his audition for “American Idol,” supposedly in exchange for learning who he would vote for, only to have him hang up after his off-key solo.
When it comes to contact tracing, Devereux’s capacity for empathy has largely helped her earn the trust of those she calls, even if it doesn’t make the situation any easier. One man began to cry while on the phone — his cancer-stricken wife was diagnosed with covid-19 and though he was staying at home, his boss was threatening to fire him from his job as a cook. Devereux had wished she could have him a hug, but through the Spanish translator, she could only repeat: “You’ve done nothing wrong. That’s so unfair.”
Even with the right people hired as contact tracers, trust in the program hinges on another factor: institutions. Gurley, of Johns Hopkins, says her course trains contact tracers in effective communication, but the responsibility of building trust starts with the public health departments, elected officials and community and religious leaders. “An analogy would be this — it’s not the job of the person who vaccinates you to ensure that you trust vaccines as a public health intervention. Sure, they’re part of it, but the job of building trust started a long time before you ever went in for the job,” Gurley wrote in an email.
Public health departments try to build this trust by advertising job openings in different languages and through community organizations. But trust in public health departments stems from trust in an even larger institution — as a 2017 study on the Ebola crisis in Liberia found, a lack of trust in the government directly corresponded to a lack of adherence to public health guidelines.
This fraying of trust in the government is particularly evident online. Ross, the Arizona State University professor, noted that comments on her and Muldoon’s Slate article came from people who dismissed contact tracing for reasons along the lines of “we can’t trust the government.” Some conservative politicians and pundits have gone further to deem contact tracing “Orwellian” or “the enemy of the people.” BuzzFeed News reported earlier this month that some contact tracers are even facing death threats online.
As deeply concerned as Ross is about these divisions, she hopes that the country is approaching an inflection point, particularly after the past month of protests following George Floyd’s death. “The observations around race and violence and the need to join as communities — I really hope that that translates to the shared work we have to do for public health,” she says. “Because I think that we’re going to be in a situation where we have to do this again in the future.”
It’s unsurprising that women are leading this work, says Bray, the deputy executive director of NYC Test and Trace Corps. “Women are so often in the position of being community builders and healers,” she says. “Public health is an arena in which there are so many women who are leaders and that’s because public health, in distinction to the medical profession, is all about community.”
And when it comes to fostering trust over a single phone call, biases about women’s voices — considered more “helpful” in regard to AI tools like Siri or “better listeners” vis-a-vis female doctors — may work to the benefit of contact tracing. “There’s a reason that when you get on the subway in New York it’s a woman’s voice that you hear on the overhead,” Ross says.
Still, she adds, though gender may play a role, “there are so many generational and cultural lived experiences that go into how one person perceives another person.”
Some contact tracers have already begun to see their calls bridging communities. One time, Devereux had to ask a woman, a mother like her, to quarantine after being exposed to someone with the virus at the assisted living place for people with disabilities where she works. As the woman stayed at home with her teenage daughter, Devereux followed up frequently to see how she was feeling. Soon, the woman recognized Devereux’s voice when she picked up the phone.
Devereux was touched. The woman knew only Devereux’s first name and the sound of her voice.