S1E38 / Shoe-Leather Epidemiology / Jay Varma, Kimberly Joceyln, Maryama Diaw

Hi, this is Zack Dyer. I'm the producer of the Epidemic podcast. And before we get to today's show, there was a small favor you could help us out with. Nominations for the 2020 People's Choice Podcast Awards close at the end of July. To show your support, please go to podcastawards.com and nominate Epidemic in the People's Choice and Health categories. That's podcastawards.com. Thanks for your support.

I'm Dr. Celine Gounder, and this is Epidemic. Today is Friday, July 24th. Kimberly Jocelyn loves to travel. Back in February, she had been visiting the Cayman Islands when she first started paying close attention to news about the coronavirus. She had another trip planned for March, one she'd been looking forward to for a long time: 2 weeks in Italy with a stopover in Ireland for St. Patrick's Day.

And the borders started to close. And it was like, wow, people are dying. People are getting sick. This is serious. And I said to myself, I, what can I do as a public health and social work practitioner within my capabilities to help the nation?

After Hurricane Sandy in 2012, Kimberly had worked as a crisis counselor helping families who'd lost their homes. She went out into the field, met with people, and helped connect them with resources.

So it's meeting them where they are and helping them find some sort of new normalcy.

Right now, that new normal in New York City is several hundred new cases of COVID every day. That's much lower than the peak back in March and April. But if the city is going to safely reopen, there needs to be a way to find cases of COVID track them, and hopefully prevent the spread of the virus. Kimberly saw how COVID had interrupted her community and wanted to help. So she got a new job.

Hi, this is Kimberly Jocelyn. I'm calling from the New York City Test and Trace Corps. I'm calling about a health matter. Is this so-and-so? And they'll confirm their identity and then inform them that this is a recorded line. That's how I typically just start with the call.

Kimberly is one of the 3,000 people the city has hired to help track the spread of the virus and limit its spread.

It's about the case and contact being informed and also being able to safely separate and providing them with resources and hoping that they will be transparent because it requires a collaborative effort from all New Yorkers. So I, yeah, I literally love my job and I love being able to wake up at the end of the day and also say like, I possibly helped save a life.

In this episode of Epidemic, we're going to be looking at COVID contact tracing in America's biggest city. We'll hear why contact tracing is such an important part of reopening our economy and hear from other contact tracers about how they're working to keep New York City safe. Dr. Jay Varma is a physician and epidemiologist in New York City. He's been advising the mayor and other New York City officials during the pandemic, including the contact tracing program.

So what contact tracing does is allow us as a public health agency, when somebody is found to have the infection, to try to find all of the people within that person's network who may also be at risk of having that infection.

Contact tracing is like building a map of how a virus spreads from one person to another. If someone tests positive for COVID, you need to contact all the people in their social network—everyone from friends and family to coworkers and more—who may have been exposed to the virus.

By doing this, what you're trying to do over time is trying to reduce the number of people that can be infected when any one person gets infected. So if I get infected and let's say on average I might infect 2 people, you're trying to find me early enough and separate me from other people so that maybe I only infect 1 person instead of 2 people. And over time, that will reduce the number of people in a population that can be infected.

Contact tracing is old-school epidemiology. It's commonly used to track the spread of tuberculosis and sexually transmitted infections like HIV. But COVID isn't like those other diseases.

So what are those specific differences? The first one is this infection can spread while people have no symptoms at all. So by the time you diagnose a person with COVID you're already behind because they have already potentially infected other people. The second reason it's challenging is because the incubation period, that is the period between when you are first infected and when you develop symptoms, is much shorter for coronavirus than it is for, say, HIV or tuberculosis or even syphilis. And so you have to also be able to act incredibly quickly.

The other major problem is even when contact tracers find people infected with COVID they don't have a treatment to offer them. Another big hurdle is trust. When Jay and I were working in West Africa during the Ebola epidemic, we both saw how public health measures could fall apart when people didn't trust their government. Today in the United States, many people of color, immigrants, and other marginalized groups are wary about sharing any information with public authorities.

So one of the most important things that we did in the design of this program was make sure that we hire personnel from, first of all, they have to be New York City residents, and second of all, that they represent all of the communities of New York City. We very carefully screen that during the interviewing and hiring process, both for geographic representation, but also to look at issues like, you know, language competence and cultural fluency.

That's why someone like Kimberly's a great fit. She has the right professional background, she's a local who grew up in Brooklyn, and she brings important soft skills like her fluency in Haitian Creole. Another contact tracer with similar skills is Mariama Jo.

So my name is Mariama Jo. I am from Harlem, so I'm born and raised in Harlem, born to Senegalese parents, and I am currently a rising second-year student at Columbia's School of Public Health.

Mariama grew up in East Harlem. Besides leaving for college, she's lived there for her entire life.

Yeah, East Harlem is just a very, very vibrant community. So it is largely Hispanic, but there is also a very large Middle Eastern population, a very large West African population. Like my family, we're from Senegal. So there's basically everyone from all over the world. You will definitely hear a car blasting the newest song that's on like the top 100, the newest rap song. You also hear bachata playing. You hear people yelling in Spanish, yelling in like a whole bunch of different languages. So it's a very diverse and eclectic neighborhood, and I really appreciate it. And it keeps you on your toes. Like, I'm glad that I don't live in a neighborhood that's boring. So it can be loud to someone who's not used to it, but for me, it's just like the normal soundtrack for my life.

So how has being from Harlem influenced your work?

It completely changes the way that you look at making the calls because you know that the people you're talking to come from similar environments. I think growing up in Harlem has prepared me a lot for this because I have had a range of responses to my calls, and that's kind of what I would expect from people from New York City. So sometimes people are pretty they're easy to talk to and they're willing to give that information. But then there are other times where people are not trusting of who's calling. And obviously, like, I understand because just the way, the way that everything has happened with how governments have reacted with coronavirus. So I've gotten a range of different reactions from different people.

Once Mariama has someone on the phone, she starts to collect their information.

Yeah, so the most important part of the call is, first of all, seeing how they're doing, seeing if they're displaying any symptoms that are worrying. And that require emergency attention. And then also getting them to understand the kinds of symptoms that they should be looking out for if they do develop within the course of their infectious period. But then also we're trying to see, okay, who have you been exposed to since your symptoms began? That way we can contact them and also make sure that they are not developing any symptoms and that they know how to safely self-quarantine as well.

Contact tracing isn't just running down a script. It requires a lot of patience and empathy. Telling someone they may be infected with COVID requires a delicate touch.

So a few days ago, I was talking to someone who she didn't know that her test had come back positive yet. So I was the first person to tell her, and usually that's a pretty hard thing to do because the person is obviously kind of sad. But she, she let me know, like, if I am in— if I'm sounding kind of sad throughout the call, it's because I'm just finding out. So we kind of took a step and we just talked for a bit as person to person. That's been really nice just to help someone through that diagnosis and to just to let them know, like, this is something that we can get through, essentially, and that I have the resources that you might need and that there are people out here trying to support you to make sure that you have what you need as well.

This information helps the city trace a path of infection and, if all goes well, get someone who's infected with COVID to isolate before they infect someone else. But pulling this off in a city as big and diverse as New York is no small feat. There are literally hundreds of languages spoken in New York City. Contact tracers who speak multiple languages are key to making this work. Mariama, for example, speaks Wolof. That's a language spoken in Senegal, where her family's from. This is where translators become so important.

Yeah, so I've seen a lot of cases where Mandarin was needed, and then also Haitian Creole has been coming up a lot. I also have had some cases who speak Russian, so that's been pretty interesting too. And then of course, a lot of cases need Spanish translators.

Once tracers like Mariama make contact with someone who needs to isolate, she offers them supports to help them stay at home and complete their 2-week isolation safely. Here's Jay Varma again.

Yeah, this is an incredibly challenging epidemic, not just because of the disease, but obviously because of the economic crisis at the same time. So even under normal circumstances, it is a lot to ask people to stay isolated for 10 or 14 days.

Jay says the most common requests they get from people in isolation are food and medication deliveries. A lot of people are also worried about losing their job if they have to isolate. And if they need it, the city even has an option for people exposed to coronavirus to isolate in hotels.

One of the reasons we wanted to do that was one, because we wanted to make sure that people would have a safe place to spend their time in isolation or quarantine where they wouldn't be at risk of infecting other family members. And the second was the potential benefit to them also because we thought that, you know, when they're in a hotel where there's, you know, closer onsite medical supervision, this might sort of improve their outcomes as well.

But there was a snag. Most people didn't want to leave their home.

You know, I think the average person, I think as we all do, feels most comfortable in their home. So I think that's one huge thing. I mean, I just think it's just a question of basic comfort and trust. You know, I've traveled and lived all over the world in some very difficult places. Honestly, the only time I get homesick is when I'm in a foreign country and I'm deathly ill. Then I care about nothing more than being back in my home bed.

There are other considerations that keep people at home, like who would take care of children or elderly family members at home while someone's away in isolation. But all these services can only be provided if the city's health authorities can reach the people they're looking for.

We know that from our experience working on many different infectious disease epidemics here in New York, whether it's the ongoing ones that we do contact tracing for, or whether it was the West Africa Ebola epidemic where we had to do extensive monitoring of people. So we knew at the outset that we needed a system that was going to be primarily phone-based with fields— by phone-based, I mean a phone banking type system where people are calling people directly on their phones, and also supplemented by people who would go knock on doors.

The New York Times, Politico, and others have been highly critical of New York City's contact tracing program. Just over 60% of coronavirus cases have completed the intake interview to identify their contacts. But it's also important to recognize that New York City is the only jurisdiction publicly reporting this level of detail. And transparency about what's working and what isn't is the first step to improving the process.

One of our biggest challenges is that, you know, our data starts with laboratory reports, but not all laboratory reports have a phone number and an address for everybody. So we've set up an entire team of researchers whose only job is to find identifying contact information, and it's really boosted the percentage of people that we can find.

The challenges of collecting and acting on this information are colossal. Coronavirus is incredibly contagious and has been spreading in the city and the nation for months now. For contact tracing to effectively stop the spread of the virus, tracers need to reach people and get them to isolate up to 2 days before they develop symptoms. Contact tracing is important, but it needs to be layered with other measures as well.

So we know number one, the most important thing is for people to be wearing face coverings and observing all of the, you know, basics of respiratory and hand hygiene that we want everybody to do. But another approach to doing that is to make making testing widely available and almost effectively a routine part of your regular health maintenance.

Jay says New York City could run up to 50,000 COVID tests a day, but a fraction of that, between 15,000 and 35,000, are seeking testing. More needs to be done to get the word out. It's not just people with symptoms or who've had a known contact who should get tested.

If you look at the infectious disease modeling approach, and of course there are a number of economists who've now become amateur epidemiologists as well, almost all of them converge on this notion that the only way you really suppress virus transmission is by mass testing. And the logic for that is that you're just trying to basically at any given time divide the population into two groups: those who can transmit infection and those who can't.

The best way to do that would be something like a home pregnancy test, a test that's cheap, fast, reliable, and widely available. But it just doesn't exist yet. And testing faces some of the same challenges as contact tracing: trust. Now thinking back to the early days of the HIV epidemic, some people might have been denied housing or a job because they had an HIV-positive test, are you hearing people express similar concerns with respect to COVID, and how do you prevent that kind of thing, that kind of discrimination from happening?

I think the threat of people being discriminated against is absolutely real, and I think it's particularly true, of course, for people who have jobs where they earn an hourly wage and they don't have a contract that they can used to defend themselves, and it can be an enormous challenge. I think this gets very much to this issue about testing, that if we can really make testing widely available and normalized as it was for HIV testing, so that getting HIV tested isn't something that only dirty or dangerous people do, but it's something that everybody does, we need to think of testing in the same way. Testing is something that responsible people do. To make sure they haven't gotten infected and they're not at risk to other people. And I think the more that that is normalized, I think the less likely we will see people who are losing their jobs or friend networks or any other potential loss of your life related to COVID infection.

COVID has exposed a lot of weaknesses in our social, economic, and public health systems. For Mariama, the contact tracer from East Harlem, it's no surprise that low-resource neighborhoods like hers have struggled with COVID Many of the people who live there have low-wage essential jobs that put them at higher risk of exposure. They tend to live in households with lots of family members, another risk for COVID infection.

I understand that it's very hard to have coronavirus and also be living in a low-resource area. And as we can see, so many low-resource areas in New York City have been so negatively affected by the virus.

But working as a contact tracer has also been an inspiration for Mariama.

I guess COVID-19 has reinforced my desire to do research in my life because I I feel that a lot of the ways that we've been affected in East Harlem could have been avoided if we had had the resources to begin with. And I think that research is a very essential part of that because if you don't know what people need, you can't get that to them. So it's kind of like reinvigorated that feeling in me, and I'm only in— I've just finished my first year of my MPH program, so I'm looking forward to bringing this experience forward to my classes and then also like post-graduation, bringing that forward to my career as well, just to make sure that my communities are actually taken care of before pandemics like this arise.

Epidemic is brought to you by Just Human Productions. We're funded in part by listeners like you. We're powered and distributed by Simplecast. Today's episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Sonia Baradwa, Annabel Chen, and Julie Levy. Special thanks to Savanthi Vasanthan. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. We release Epidemic twice a week on Tuesdays and Fridays, but producing a podcast This costs money. We've got to pay Zach. So please make a donation to help us keep this going. And check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In season 1, we covered youth and mental health. In season 2, the opioid overdose crisis. And in Season 3, Gun Violence in America. I'm Dr. Celine Gounder. Thanks for listening to Epidemic.