How to quickly scale up contact tracing across the US

Contact tracing -- the process of identifying people who may have been exposed to the coronavirus in order to slow its spread -- is a fundamental tool in the fight against COVID-19. How can we scale this critical work across the entire United States? Joia Mukherjee, chief medical officer of Partners in Health, discusses how her team is working with public health agencies to ramp up contact tracing for the country's most vulnerable communities -- and shows why it will take a compassionate approach to be truly effective. (This ambitious plan is part of The Audacious Project, TED's initiative to inspire and fund global change. The conversation, hosted by head of TED Chris Anderson and current affairs curator Whitney Pennington Rodgers, was recorded May 27, 2020.)

Chris Anderson: Joia,
both you and Partners In Health

have spent decades
in various battlegrounds,

battling epidemics.

Perhaps, for context, you could give us
a couple examples of that work.

Joia Mukherjee: Yeah,
so Partners In Health

is a global nonprofit
that is more than 30 years old.

We started famously in Haiti
in a squatter settlement,

people who were displaced.

And when we talked to them,

they wanted health care and education,

houses, jobs.

And that has informed our work,

that proximity to people
who are suffering.

When you think about
health care and the poor,

there is always disproportionate suffering

for people who have been
historically marginalized,

like our communities
that we serve in Haiti.

And so we've always tried
to provide health care

for the poorest people on earth.

And we were launched
into an international dialogue

about whether that was possible

for drug-resistant tuberculosis, for HIV.

Indeed, for surgery, for cancer,

for mental health,

for noncommunicable diseases.

And we believe it's possible,

and it is part of the basic
human right to care.

So when COVID started,
we saw this immediately as a threat

to the health of people
who were the poorest.

And Partners In Health
now works in 11 countries,

five on the African continent,

Latin America and the Caribbean,

as well as the former Soviet Union.

And we immediately prepared
to scale up testing,

contact tracing, treatment, care,

and then saw that it wasn't being done
in the United States in that way.

And in fact, we were just sitting,
passively waiting for people to get sick

and treat them in hospital.

And that message got
to the governor of Massachusetts,

and we started supporting the state
to do contact tracing for COVID,

with the very idea that this would help us
identify and resource

the communities that were most vulnerable.

CA: So it's really quite ironic
that these decades of experience

in the developing world and elsewhere,

that that has now really been seen
as a crucial need to bring to the US.

And especially to bring your expertise
around contact tracing.

So, talk a bit about contact tracing,

why does it matter so much,

and what would, I don't know,

a perfect contact tracing setup look like?

JM: Well, first I want to say
that you want to, always,

in any type of illness,

you want to do prevention,

and diagnosis and treatment and care.

That is what comprehensive
approaches look like,

and that "care" piece, to us,

is about the provision of social support
and material support

to allow people to get the care they need.

So that might be transportation,
it might be food.

So when you look
at that comprehensive approach,

for an infectious disease,

part of prevention is knowing
where the disease is spreading

and how it's spreading
and in whom it's spreading,

so that resources can be
disproportionately put

to the highest-risk areas.

So contact tracing
is a staple of public health

and what it means is that every time
a new person is diagnosed

with COVID or any infectious disease,

then you investigate and innumerate
the people they've been in contacts with,

and call those contacts
and say, "You've been exposed,"

or talk to them, "You've been exposed,

these are the things you need to know.

First of all, how are you?

Do you need care yourself?"

And facilitating that.

"Second of all, these are the information
you need to know to keep yourself safe.

About quarantine, about prevention."

And again, this would be
with any infectious disease,

from Ebola, to cholera, to a sexually
transmitted disease like HIV.

And then we say,

"OK, knowing what you know,

do you have the means
to protect yourself?"

Because often the most vulnerable

do not have the means
to protect themselves.

So that is also where this resource
component comes in

and where equity is so critical

to making this disease stop

and also getting the information
and the resources

to people who need them the most.

CA: And in a pandemic,
the people who need them the most,

the most vulnerable, as you say,

are probably also --

That's where the disease
is spreading a lot.

It's in everyone's interest to do this.

You're not just making this sort of,
wonderful, equity moral point

that we've got to help these people.

It's actually in all
of our interest, right?

JM: Yes.

Yes, we are one humanity,

and any disease, any infectious
disease that is spreading

is a threat to all of us.

And that is one of the pieces,
there's the moral imperative,

there is the epidemiologic imperative,

that if you can't control
these diseases everywhere,

that it's a threat anywhere.

And so as we look to the kind
of society we want to live in,

good health is something that gives us all
so much return on our investment.

CA: Now, some countries were able
to use contact tracing

almost to shut down the pandemic
before it took off in that country.

The US was unable to do that,

and some people have taken the view

that therefore, contact tracing
became irrelevant,

that the strategy was mitigation,
shut everything down.

You've argued against that,

that even in a process of lockdown

that actually contact tracing
plays a key role.

Help us understand the scale,

when there's a lot of cases,

the scale of tracing, both cases

and everyone they may
have been in contact with

and their contacts.

It quickly gets to a huge problem.

JM: It's massive.

CA: What sort of workforce do you need
to make a difference

at this moment, where the US is at?

JM: It's massive.

I mean, the scale is massive,

and we should not take that lightly.

And we don't, at Partners In Health.

I mean, we are willing
to try to figure this out,

and I always feel
that if we could stop Ebola

in some of the poorest
countries in the world,

of course we ought to do it here,

and was it too late when there were
28,000 deaths in Ebola?

Sure, it's always too late.

We should have started earlier,

but it's not too late to have an impact.

And so there's three aspects
of timing and scale.

First is, the earlier you start,

the better, right?

And that's what we saw in Rwanda.

They went from early testing
and contact tracing,

the first two cases entered
into the country on March 15,

and in one month,

because of contact tracing,
isolation and plenty of testing,

they had held that case rate
to 134 people.

It's remarkable, it's remarkable.

In the state of Georgia,
where is home to the CDC,

similar population size, about 12 million,

from the first two cases
in the first month,

those cases became 4,400 cases.

And in the country of Belgium,

a similar population,

those two cases became 7,400.

So you do have to make scale to stop this.

But the earlier you do it,

the more benefits there are
to your society

and also to the other people
who need medical services --

women who are pregnant,

people who need their fracture repaired,

because services themselves
in the United States

have been, you know, really hampered
by this huge amount of COVID.

So the first point is,

it's always late, but it's never too late.

Why?

Because vulnerable populations
are sitting ducks,

and so imagine if one of your contacts
was a nursing assistant

who worked in a nursing home.

We know that one nursing assistant
can spread it throughout a nursing home.

And is it important to identify
that person as a contact

and assure that he or she
is able to remain quarantined?

That is critical.

And so it's hard to say,

"Well, it's not worth it
if it's just one person, two persons."

Every life matters,

and all of their contacts in the community
of that person matters as well.

So that's one thing.

The second about scale
is people need jobs right now.

And they want to be part of a solution,

and some of the frustration we see,

the antilockdown movement,

is really out of anger and frustration

and feeling, "What can we do?"

And so this gives people this feeling
that they're part of a solution

and can provide thousands of jobs.

And then third, I would say,
for us to reopen our schools,

our churches, our workplaces,

we have to know
where the virus is spreading

so that we don't just
continue on this path.

And so contact tracing provides
the platform to control,

but also to see outbreaks
in real time popping up,

and then respond promptly.

So there are many reasons
that we have to bring this to scale now.

Even though it is tardy.

CA: So especially as we have
this pressure to go back to work,

like, contact tracing
has to be part of that strategy,

or we're just inviting another disaster
in a few weeks' time.

Whatever you make of what's happened
during this mitigation process.

JM: Exactly, exactly.

Exactly, and so that's such
an important part, Chris,

and something that we are just really keen

to look at the United States
in a different way.

What are the long-term
public health infrastructures

that we need to protect us
for the second wave, the third wave

and in the future, for future pandemics?

CA: Whitney.

Whitney Pennington Rodgers:
You know, to that point,

there is a question out there
from one of our anonymous

community members,

about why contact tracing isn't already
part of our public health system.

It seems like it does make a lot of sense

its a way to mitigate
the spread of disease.

Could you speak a little bit to that?

JM: I think many people have said --

and I am not a politician --

that our American
health care infrastructure

is built on treatment and not prevention.

It's built on procedures

and not keeping people well.

And some of that was driven by profit,

and some of that was driven by need,

but I think we need to rethink
how we deliver care in this environment.

WPR: "There is some fear and suspicion
about privacy and contact tracing.

How can we build trust in the process?"

JM: Yeah, that's a great question,

and I think there's fear about privacy

and part of it comes from the idea
of what contact tracing is.

And I think that's why we feel strongly,

is if you lead with the idea
that it's care

and it's trying to get
resources and information

and help to people,

it seems very different

than just, oh, who's sick,
and who's a threat.

And so fundamentally --

and that's why we're so pleased
to be at this TED talk today --

is it's about communication, right?

It's not about surveillance,

it's about communication
and care and support.

That's one thing.

And we'll be hearing from our colleagues

on the tech side.

There's ways to add tech, even to care,

that it can be a resource
for caring and communication.

But there are ways
to protect people's privacy

and also to provide care,

and public health has many
laws attached to it.

This is all done within the constructs
of our state public health laws.

And so I think some
of the communication around this is,

how do we take care of each other,

how do we take care
of the most vulnerable.

And if we frame contact tracing as care,

I think that starts
a different kind of conversation.

CA: Mm.

So, Joia, can you just talk
in a bit more detail

about what it is that you are advising
Massachusetts to do

in terms of contact tracing.

Give us a sense of the scale of it.

JM: Yeah, so the scale -- thank you.

You know, we are able now
to make about 10,000 calls a day

to contacts.

So every new case that comes in,

the case is investigated
by someone on the phone,

and then those investigations

means writing down the names
and the phone numbers of the persons

you've been in contact with
for the time you were sick

and a couple days before.

And with those numbers then,
the contact tracers --

And that's what we really redoubled
the workforce and really expanded,

more than doubled,

to support the department of public health

to do that contact tracing.

So we have 1,700 people employed
full time, with benefits,

to call those contacts
and say, "Are you OK?

This is the information you need,"

and then, and I think
this is the critical piece,

when someone doesn't have the information,

then we have another cadre of people
we call the resource care coordinators,

who help that person, that contact,

to do the things they need to do
to protect themselves.

It might be food delivery,

it might be filing
for unemployment benefits,

it might be trying to get them
medical care or a test.

That piece is the care piece.

And that is what turns social distancing
from very regressive --

look at me in my beautiful house,
social distancing --

to something that's progressive

and paying attention
to those who need the resources.

So the scale is massive,

with 1,700 employees hired to do this,

but they are connected

with local community food banks
and churches and facilities

and primary health care centers as well.

CA: Thank you so much, Joia.