Charting a Course for Public Health Based on Lessons from Contact Tracing During the Pandemic

Preview quotes:

[CANDACE MILLER]

What's the saying? Nothing about us without us, having people all of a community are going to be better able to connect with other people from that community because they can sort of meet and understand each other.

[RACHEL BRASH]

We wanted our contact tracing staff to reflect the demographics of the city.

[CANDACE MILLER]

This was a case where trust was so so important and you only have, you know, maybe a sentence worth of time to establish that initial trust for people who may hang up if they don't hear in the call or something that pulls them in right away.

[ELINOR HIGGINS]

When a state is getting thousands of new cases every day, it becomes fairly impossible for staff to actually do all of them and notify all of their contacts and so on. It just really can't be done manually.

[SHAN-TIA DANIELLE]

Mentally, this is the absolute, most draining job that I've ever done.

[ELINOR HIGGINS]

If you have folks who are doing these jobs, and who are in these roles, who are becoming quite burned out as they're, you know, through these sort of cycles of boom-and-bust funding and through, working really long hours, because maybe the staffing numbers aren't what they should be. And, like, I mean, all of that, that both is detrimental to the institutional knowledge, but it also can be a challenge for things, like, just helping people move through career paths and public health at every level.

[CANDACE MILLER]

Yeah, so right now, the state of data, the sort of architecture, the ability to get a piece of data from one place to the next, is dismal. It is sadly, pathetically, dismal.

[SHELLEY FISCUS]

Right now, today, we're probably less prepared for the next pandemic than we were in 2019.

[CANDACE MILLER]

The opportunity now is to plan for the next 20 to 40 years, really. In electricity they say, you know, you've got to think about the grid that you want 40 years from now and start working towards that, and really public health needs to be thinking in that way, too.

[J.B. WOGAN]

I’m J.B. Wogan from Mathematica and welcome back to On the Evidence, a show that examines what we know about today’s most urgent challenges and how we can make progress in addressing them.

On today’s episode, we’re going to focus on case investigation and contact tracing, public health tools that played leading roles in the early days of the U.S. pandemic response but have since been scaled back.

Contact tracing has come up on the podcast before. It’s one of the areas where Mathematica played a part in combatting the pandemic. We helped run a contact tracing program in one state and we supported another contact tracing program in a major American city. We also partnered with several other philanthropic and nonprofit organizations to provide data to decision makers and the public about different emerging approaches to contact tracing, with the hopes that better information might lead to more effective containment strategies and less disease spread overall.

As we record this podcast in late September of 2022, we remain in a federal public health emergency. At the time of this recording, the United States is still averaging more than 45,000 new cases of COVID-19 per day, resulting in more than 3,500 hospitalizations per day, and almost 325 deaths per day, and that’s according to the Centers for Disease Control and Prevention.

At the same time, much has changed since we first featured contact tracing on the podcast. The universal approach to case investigation and contact tracing in the U.S., as I’ll explain in a second, has been phased out. Many of the policies that made life feel less normal, like mandatory masking on airplanes, have gone away. So I wondered, at this point, when we’ve reached a new chapter in the pandemic, where contact tracing is playing a much more narrow role in managing the spread of COVID-19, what did we learn? And, in particular, what lessons still apply even in a world without a pandemic? Because even if the next pandemic isn’t imminent, new concerning developments in infectious disease have already arrived. This summer, the CDC declared the current monkey pox outbreak a public health emergency. Also this summer, the New York State Department of Health detected the first U.S. case of polio caused by wild poliovirus since 1979. Disease investigation and contact tracing have already played a role in understanding the scope of the problem with both diseases and have helped to prevent further infections.

Whether we learn from our experiences with contact tracing during the pandemic could determine whether we put to good use the several billion dollars that Congress has made available to state, tribal, local, and territorial governments in support of the nation’s public health workforce. There’s considerable flexibility in how the money can be spent, but one allowable purpose is for costs related to recruiting, hiring, and training contact tracers and other disease investigation staff. Public health agencies can also use the funds for workforce analyses that would inform hiring goals and even the reorganization of entire departments to better prepare for future emergencies.

With so much money at stake, it’s worth asking what the last couple years have taught us about building and maintaining a public health workforce for pandemic preparedness. And specifically, what should we be investing in now to ensure that our capacity to conduct case investigation and contact tracing is stronger when the next crisis emerges. This episode is an attempt at surfacing at least some answers to those questions.

…

Okay, let’s rewind for a second.

In the first few months of the pandemic, when vaccines hadn’t been developed yet and rapid, home-based tests weren’t widely available yet, case investigation and contact tracing were a central pillar in the U.S. public health strategy for containing the spread of COVID-19. When someone tested positive for the virus, the result would go to a state or local public health department, which would lead to calls from case investigators and contact tracers. On those calls, people would learn about the disease, how to keep others from getting sick, and in some cases, how to access other support services if they needed help while dealing with any work disruptions caused by the infection. A contact tracer would then notify the infected person’s close contacts that they might have been exposed to the virus and needed to quarantine.

This approach was called universal contact tracing. In those early days, health departments sought to investigate and contact trace every case of COVID-19. As the virus spread, state and local health jurisdictions hired more contact tracers to keep up with the rising the number of cases and contacts.

By June 2020, the U.S. had around 28,000 contact tracers, a major uptick from the 6,000 or so at the start of the year. But Robert Redfield, the director of the Centers for Disease Control and Prevention at the time, told Congress that 28,000 still wasn’t enough.

He said the country needed at least 100,000 contract tracers.

At its peak, the national contact tracing workforce came close to that number, about 70,000, according to estimates from National Public Radio and the Johns Hopkins Center for Health Security. But today, the U.S. public health strategy around contact tracing and COVID-19 looks quite different. Earlier this year, the CDC updated its recommendations to state, tribal, local, and territorial health departments and told them to prioritize case investigation and contact tracing only for specific settings and groups at increased risk.

[ELINOR HIGGINS]

For the most part, states have stopped doing a universal, sort of population-wide contact tracing and there are a number of reasons for that.

[J.B. WOGAN]

That’s Elinor Higgins, a policy associate at the National Academy for State Health Policy. Her organization, in partnership with Mathematica, maintains an online database that tracks trends in state approaches to contact tracing during the COVID-19 pandemic.

[ELINOR HIGGINS]

The large number of cases is definitely one. Not knowing about all the cases is definitely another. And the higher rates of vaccination is yet another.

[J.B. WOGAN]

A few things changed between those early days of the pandemic when contact tracing was considered a key strategy for getting things under control. One positive development, as Elinor mentioned, is that vaccines became widely available in the U.S. and a lot of people took advantage of them. About two-thirds of Americans are fully vaccinated, not including the additional booster shots that have also become available. A large share of the population also has some immunity from a prior infection.

By this point, many Americans have protection from both the vaccine and a prior infection.

As more people have that protection, they are at lower risk of severe illness, hospitalization, and death from the disease, which means the urgency to track down every case has lessened.

The highly infectious Omicron variant and its sub-variants also forced a few changes. Here’s Elinor again.

[ELINOR HIGGINS]

I mean, when a state is getting thousands of cases, new cases, every day, it becomes fairly impossible for staff to actually do all of them and notify all of their contacts and so on. It just really can't be done manually.

[J.B. WOGAN]

But the problem wasn’t just that states couldn’t keep up with the case load. States couldn’t even say what the true case load was. That’s because, in the face of a winter surge of cases driven by Omicron, the Biden administration pivoted to encourage the use of rapid, home-based tests that would allow people to find out within 15 minutes whether they had been infected. Anyone who signed up on a government website could receive in the mail two tests for free and you could be reimbursed by your health insurance provider for additional tests you purchased.

Those tests had advantages over PCR tests administered by a health professional, such as faster results and the convenience of not needing to go somewhere to get swabbed. But one downside was less complete data on case counts. When someone tests positive on a PCR test, the medical lab processing the test reports the result to local public health authorities. Now, with home-based tests, the onus has shifted onto individuals to tell their health provider and close contacts if they get a positive result.

So even though state, local, and territorial jurisdictions now have federal funds to boost the number of public health workers across the country—and they will surely use the money to strengthen their long-term capacity for case investigation and contact tracing—they’re not about to stand up a workforce the size once envisioned at the beginning of the pandemic. Instead, they’ll apply lessons from what worked, and didn’t, during the pandemic for a more effective and rightsized workforce going forward.

One lesson from the pandemic is that public health workers can better achieve their objectives around infectious disease control if they’re ready to address people’s social needs as well.

[SHAN-TIA DANIELLE]

Contact tracing is something that really hit home for me because of that personal aspect of connecting with people and working in a contact tracing position where you also are providing resources.

[J.B. WOGAN]

That’s Shan-Tia Danielle. She joined the Washington State COVID-19 Contact Tracing Partnership as a contact tracer and eventually led a team of 30 or so contact tracers. On any given call, contact tracers like Shan-Tia could encounter someone in crisis—even when the person’s COVID symptoms weren’t severe.

[SHAN-TIA DANIELLE]

Health care goes beyond the illness itself. It affects every other part of our life.

Many families weren't able to work and couldn’t have, didn't have money to pay for food just to keep everyone fed or keep the lights on or pay their rent.

[J.B. WOGAN]

Shan-Tia remembers one case where both parents and their daughter were sick. Shan-Tia had called for a routine checkup to see how the daughter’s symptoms were progressing.

[SHAN-TIA DANIELLE]

And the mom said, I'm not answering any more of your questions because I've talked to this person and this person, this person. I've told them what we need. You guys have said that you guys would offer resources.

We reached out. No one's doing anything and we're going to lose. We're not going to be able to have utilities because we can't pay for it. And no one's helping, even though you guys are saying you will. And I took that very personally because I heard the stress. I heard the worries.

[J.B. WOGAN]

Ultimately, Shan-Tia was able to flag the case for her supervisors, who worked with social service providers in the family’s area to cover the family’s utility bill and provide an extra couple hundred dollars for other expenses. In public health, the practice is sometimes called resource coordination and it became more common during the pandemic. One story on NPR called it “a secret weapon in the pandemic public health response.” Those resources could take the form of food and grocery delivery, extra masks, cleaning supplies, or even providing hotel rooms for those who could not isolate from other household members in their own homes.

Sometimes, as Shan-Tia learned, public health workers have more luck earning people’s trust if they’re able to go beyond asking questions about disease spread and use a more empathetic, human-centered approach. Resource coordination also ensured a more equitable approach to contact tracing, as many of the households that were in need of financial assistance had lower incomes.

A cruel reality of the pandemic, however, was that public health workers had to balance the benefits of closing that emotional distance between themselves and the strangers on the other end of the phone to see the whole person and respond more fully to their needs while also maintaining some emotional distance for calls that often turned hostile. Here’s Shan-Tia again.

[SHAN-TIA DANIELLE]

I think the biggest thing that you need to be a contact tracer is thick skin. You need to not be able to take things personally because the pandemic is a very controversial, unfortunately, very controversial topic. And many people are in heavy denial about it. And whether they tested positive or not, which is kind of baffling that they're experiencing the symptoms and experiencing it, but still deny it, but you'll get cussed at, you'll get cursed up and down. There will be people that will speak bad on your character, of who you are as a person. And it's really hard to hear those things over and over and over and over and over again throughout the day and not take that personally.

[J.B. WOGAN]

The hostile reception Shan-Tia sometimes encountered on calls connects with another takeaway from contact tracing during the pandemic: public health workers were often stressed and burned out, not only because the nature of the calls could be emotionally draining, but also because they were working long hours when case counts would surge. Here’s Shan-Tia again.

[SHAN-TIA DANIELLE]

You're constantly on the phone with somebody. You're constantly dealing with all these rough calls. There's never a time for you to just kind of feel human and just relax. And as soon as you get off work, all you do is sleep because there's nothing else to do you. You're physically exhausted from just talking every day.

[J.B. WOGAN]

The pandemic undeniably placed greater strain on contact tracers and other public health workers. But even before the era of COVID-19, insufficient or inconsistent funding for public health had contributed to persistent problems with staffing shortages, turnover, and burnout. Here’s Elinor Higgins from the National Academy for State Health Policy.

[ELINOR HIGGINS]

If you have folks who are doing these jobs, and who are in these roles who are becoming quite burned out as they're, you know, through these sort of cycles of boom-and-bust funding and through, take really long hours, because maybe the staffing numbers aren't what they should be. And, like, I mean, all of that, that both is detrimental to the institutional knowledge, but it also can be a challenge for things, like, just helping people move through career paths and public health at every level. So, kind of building those senses of professional identity and mentorship, and all of those steps, like those can be difficult to maintain if everybody is a little bit, you know, overworked and under sort of conditions that are not sustainable.

[SHELLEY FISCUS]

Public health, traditionally, has turned over its workforce really quickly, and there's good reasons for that.

[J.B. WOGAN]

That’s Dr. Shelley Fiscus. She’s a pediatrician who works with Elinor at the National Academy for State Health Policy. Prior to October 2021, Dr. Fiscus served as the medical director of the Tennessee Vaccine-Preventable Diseases and Immunization Program at the Tennessee Department of Health.

[SHELLEY FISCUS]

The pay is usually not on par with what you would see anywhere close to what you would see in the private sector. People are often working under conditions, you know, in those crumbling buildings that don't have heat, sometimes that are not great and while they're incredibly dedicated people who are usually there for all the right reasons, sometimes opportunities to just flatly make more money and have a better work lifestyle become very attractive and people leave the workforce. And then you lose a lot of that institutional memory around, well, what happened in the last pandemic? What happened in H1N1 that should be applied to COVID-19? You lose a lot of that flavor.

[J.B. WOGAN]

The pandemic taught us that something needs to change about the way we, as a nation, build and maintain our public health workforce, Dr. Fiscus says. The infusion of federal dollars provides an opportunity to revisit recruitment, hiring, and retention strategies.

[SHELLEY FISCUS]

We're going to have to train up a new public health workforce because the one that started this pandemic is largely not in the profession anymore. They've gone on to other things. There's a wide-open job market. They can make more money and have better hours and less stress doing something else, and so we've got to make public health attractive to people who want to go and get master’s degrees in public health and PhDs in public health and to go work for state agencies and those state agencies need to be prepared to properly compensate that workforce, so that they get really good, talented, bright, dedicated people who come in and continue to do that work.

[J.B. WOGAN]

Because there was no national strategy around contact tracing and disease investigation, states and localities essentially participated in a natural experiment of different ways to quickly onboard disease investigation staff who would be fast and effective at containing the virus.

The data compiled and updated regularly by the National Academy for State Health Policy and Mathematica is instructive on just how much variation has existed in state approaches.

For example, Alabama’s contact tracers included state Department of Health employees, staff from the CDC Foundation who assisted with case investigations, as well as undergraduate, graduate, and medical school students from the University of Alabama at Birmingham School of Public Health.

In Colorado, the state had its own contact tracing team, which supported local governments and partner organizations that also hired and managed contact tracing teams. Colorado also hired AmeriCorps and Senior Corps members and deployed its National Guard to support the state’s COVID-19 response, including contact tracing. The state also leaned on a volunteer group of public health professionals to support local public health agencies by recruiting and training a contact tracing workforce and monitoring the rollout of contact tracing.

Several states and localities contracted with private organizations, including Mathematica, to hire, train, and support contact tracing teams.

In the frenzy of responding to the initial wave of the pandemic in spring of 2020, followed by future waves driven by variants of the virus, states never coalesced around a set of best practices. Each state had its own unique set of local assets, like universities and foundations, and its own constraints, like limited public funding or political hostility to contact tracing and vaccine outreach. Other factors, such as the demographics, median household income, and poverty rate, could also inform a state or local public health jurisdiction’s approach to case investigation and contact tracing. In fact, Mathematica helped develop two free online data visualizations, one with the National Academy for State Health Policy and one with the Public Health Foundation, that provided insights about how the unique circumstances of a state or locality might influence the composition of the public health workforce.

While states didn’t arrive at a set of best practices, there do seem to be some lessons that could inform future efforts in the case of an unexpectedly infectious and dangerous future variant of COVID, or another pandemic. Here’s Elinor Higgins again.

[ELINOR HIGGINS]

I think there's some consensus around what didn't work, right? I mean, so volunteer workers, just given the nature of those types of roles, folks who are in volunteer roles can be a bit unreliable or turn over quickly.

[J.B. WOGAN]

The same resources that go toward training successive groups of short-term volunteers could be going toward a permanent stable of full-time positions, she says. The turnover also affects the quality of data that contact tracers collect, which provides a critical picture of how the disease is spreading, how certain demographic and socioeconomic groups are being affected by the disease, and other information that help public health officials and policymakers understand the state of the pandemic.

States also learned that they couldn’t do everything in-house, says Shelley Fiscus.

[SHELLEY FISCUS]

I think most large jurisdictions eventually settled on the importance of having a third-party contractor that could provide workforce and help with the training and help with the interviewing – because the state agencies just couldn't do it. They just couldn't work on all these positions and running all the resumes and hiring all of them, putting them through all of the training, and so those third-party contractors helped immensely.

[J.B. WOGAN]

Another lesson might be that state and local organizations should build a public health workforce that shares a common language and lived experience with the community it serves.

[CANDACE MILLER]

I think it is best practice, but it is unique, you know, to have people. What's the saying? Nothing about us without us, having people all of a community are going to be better able to connect with other people from that community because they can sort of meet and understand each other.

[J.B. WOGAN]

That’s Candace Miller, a principal researcher at Mathematica who helped lead the Washington State COVID-19 Contact Tracing Partnership. In the earliest days of the pandemic, she also volunteered as a contact tracer in her home state of Massachusetts.

[CANDACE MILLER]

I was working in Brockton. So, Brockton is very, very diverse, economically, racially, ethnically, very, very diverse. And a lot of low-income and people of color.

[J.B. WOGAN]

Many of the early volunteers were, like Candace, white, highly educated, primarily English speakers, and, most importantly, not from Brockton.

[CANDACE MILLER]

And all of a sudden, we had people from the Brockton neighborhood health center join us. And these folks, boom, they could make an instant connection. They just, the language, the accent, the understanding of, oh, yeah, but that, you know, you could get a formula if you go to this foodbank on Tuesday or something like that. They just knew how to connect instantly.

[J.B. WOGAN]

Hiring people from the community was critical, she says, because it made for more effective contact tracing and disease investigation.

[CANDACE MILLER]

This was a case where trust was so so important and you only have, you know, maybe a sentence worth of time to establish that initial trust for people who may hang up if they don't hear in the call or something that pulls them in right away.

[J.B. WOGAN]

Those early insights in Massachusetts informed the contact tracing effort Candace help lead in Washington State. Of course, the first priority was to onboard enough case investigators and contact tracers to meet demand. But as part of their work for the Washington State Department of Health, Mathematica and its partners at Comagine Health and Allegis Global Solutions also prioritized language proficiency, cultural competence, and other forms of representation to ensure the instant connection Candace had witnessed in Brockton.

For example, the Washington State COVID-19 Contact Tracing Partnership required that at least 20 percent of the case investigators and contact tracers had to be bilingual. In reality, the workforce was often above that target. In February 2022, for example, 36 percent were bilingual, with representation across all of the languages that the state Department of Health determined to be of greatest need, including Spanish, Vietnamese, Russian, and Ukrainian. Having bilingual people on staff saved time and allowed employees to conduct the call in the respondent’s preferred language and to minimize the use of third-party translators.

The partnership also tracked how closely the demographics of case investigators and contact tracers matched the demographics of individuals who tested positive for COVID-19 throughout the state. For example, in February of 2022, about 6 percent of the workforce and 6 percent of people who tested positive for COVID were Black or African American. About 24 percent of the workforce was Hispanic or Latino, compared with 21 percent of people who tested positive.

As I mentioned earlier, in the spring and summer of 2020, states were under enormous pressure to increase the number of contact tracers to try to get ahead of community transmission. But who became contact tracers was important, too, because states needed a workforce that could get people to stay on the phone, listen to public health guidance, and answer questions about their recent in-person interactions with others. These cold calls faced some obstacles. For example, COVID-19 hit some demographic groups particularly hard, such as Black, Indigenous, and Latinx people, and in those same communities, a historical legacy of structural racism in health care settings made it more difficult for public health workers to earn the trust of residents. In some cases, respondents also may have worried that completing an interview would jeopardize their immigration or employment status or negatively affect their access to needed benefits or services.

In Washington State, Shan-Tia Danielle remembers her contact tracing team reaching people by phone whose first language wasn’t English and they would sound scared, particularly if they thought the call was about their immigration status or a legal issue.

[SHAN-TIA DANIELLE]

Having someone that did speak their language, being able to say, I promise you, you're not in trouble. This is why we're calling you. We just want to make sure that you're safe and offer those resources and offer those help. It definitely helped to see that they weren't being alienated or isolated, but they genuinely were looking to help them.

[J.B. WOGAN]

One jurisdiction that placed special emphasis on who they hired for contact tracing during the pandemic was Baltimore.

[RACHEL BRASH]

We wanted our contact tracing staff to reflect the demographics of the city. That was a goal and that's what, you know, and we ended up with, a staff whose demographics did reflect the demographics of the city.

[J.B. WOGAN]

That’s Rachel Brash, a strategist in the Mayor’s Office of Employment Development, who helped oversee a public-private partnership called the Baltimore Health Corps Initiative. From the get-go, Rachel says the city sought to hire local residents who came from the communities being disproportionately affected by COVID-19.

[RACHEL BRASH]

And so, we did know that hiring from the community would add to the credibility of the work, and would improve their success rate of the calls, and the other contacts that the contact tracers were making. And, you know, the health department staff also, in addition to contact tracing, they ended up doing mobile vaccination work and it was believed and understood that that having people from the community in those roles could only improve the effectiveness of the relationship and of the work.

[J.B. WOGAN]

What made the Baltimore contact tracing initiative unusual was its dual purpose as a local pandemic response program and a recession-era paid transitional jobs program. Mathematica provided technical assistance to the Baltimore Mayor’s Office of Employment Development by coaching career navigators who then supported the temporary workforce of more than 300 contact tracers, case investigators, and care coordinators.

When Rachel’s office began planning the initiative in the spring of 2020, the city’s unemployment rate had more than doubled, from 5.5 percent in February to 11.4 percent in April. It would peak the following month at 12.6 percent. Here’s Rachel again.

[RACHEL BRASH]

We wanted to make sure that these jobs that were being created went to people who needed them. You know, that in standing up the public health initiative, we weren't hiring, you know, just retired nurses or doctors or people with the highest education levels or, you know, the most experience in public health, that it really was, that there really was a workforce development component to it. And that was built in from the very beginning and that the jobs were benefiting people in the areas hardest hit by COVID. And many of those also were experiencing the highest levels of unemployment.

[J.B. WOGAN]

In all sorts of ways, the city adjusted its hiring process to increase the chances that its contact tracers fit the profile of people who, yes, could do the job, but also stood to benefit from a paid transitional jobs program that would equip them with new marketable skills and support them with job-placement services when the contact tracing positions ended. Here’s Rachel again.

[RACHEL BRASH]

We removed the requirement for a high school diploma for some of the positions. We thought, it doesn't need to be in there. And we didn't require health care experience. That was a plus, but we also wanted to make sure that comparable experience in customer service and social services was also considered, that we wanted people to have those skills, but it didn't necessarily need to be in a public health or a health care setting.

[J.B. WOGAN]

Beyond offering career navigation services, the city also offered legal and behavioral health services to Baltimore Health Corps hires. Employees could take advantage of those services to address a range of issues that might otherwise become barriers to their economic and career goals, such as depression, consumer debt, taxes, and costly legal disputes over child custody or child support payments.

Overall, the city received more than 10,000 applications for open positions in the Baltimore Health Corps. According to an evaluation by the policy research firm Abt Associates, about 81 percent of the people hired had lost their job, been furloughed, or had hours reduced because of the pandemic; among that 81 percent were also people who were already unemployed prior to the COVID-19 outbreak.

As intended, the workforce closely resembled the demographic makeup of the city. For example, Baltimore’s residents are 62 percent Black and the health corps hires were 51 percent Black. About 5 percent of residents are Hispanic or Latinx and the hires were about 8 percent Hispanic or Latinx.

As Rachel mentioned, the city did not require a high school diploma or public health experience for some positions, with the goal of trying to create opportunities for economic mobility for people with lower levels of educational attainment. Even so, most employees in the health corps, about 70 percent to be precise, had a college degree. Many also had relevant certifications in contact tracing and community health work.

Mathematica’s role in the initiative was to help the Baltimore Mayor’s Office of Employment Development create the transitional jobs program and implement career navigation services for the Baltimore Health Corps employees so that when their temporary positions ended, they would be successful in finding permanent jobs in the regular labor market. Mathematica’s work with the Mayor’s Office, by the way, was made possible with support from the Annie E. Casey Foundation and the Office of Family Assistance at the Administration for Children and Families.

Mathematica has published several short issue briefs that detail the work that went into designing and implementing the paid transitional jobs program in Baltimore that doubled as a pandemic response program. For example, Mathematica trained career navigators on how to use a standardized, structured process for setting and reviewing employment goals with the frontline staff in the Baltimore Health Corps initiative.

Shaun Stevenson, an advisory services analyst at Mathematica, says the initiative prompted the Baltimore Mayor’s Office of Employment Development to revisit its workflow and internal processes for supporting paid transitional jobs programs in general. Here’s one example: When the initiative launched, the office supported contact tracers and other health corps staff through career development services and job placement services. Those services were offered by two different teams within the same office, and before the health corps initiative, Shaun says the teams didn’t communicate enough.

[SHAUN STEVENSON]

It would make sense that they're working directly together, right? One's getting someone ready for a job. The other one is placing someone in the job. So, it makes sense that they would be working together, but they weren't.

[J.B. WOGAN]

Once Shaun and her colleagues at Mathematica helped surface the problem, they worked with the Mayor’s Office of Employment Development to create something called the Employment Transition Team, which comprised of a career navigator, two business services representatives, and two career development facilitators. The team met every other week to discuss the desired careers and support the needs of participants who were near the end of their time in the initiative.

[SHAUN STEVENSON]

I think that's one thing I'm really, really proud of, is just kind of closing that silo gap to really help individuals get what they’d like to get out of the program more seamlessly.

[J.B. WOGAN]

This is but one of many legacies of the contact tracing initiative in Baltimore. Even though the Baltimore Health Corps pilot ended in December of 2021, those separate teams within the Baltimore Mayor’s Office of Employment Development, one focused on job readiness and one focused on job placement, will continue to communicate and coordinate services.

Another legacy is that about 38 percent of people who joined the city as part of the Baltimore Health Corps Initiative found long-term positions with the Baltimore City Health Department or HealthCare Access Maryland, a Baltimore-based nonprofit involved with the initiative. Another 36 percent of the Baltimore Health Corps workforce moved onto a new opportunity, such as a new job, graduate school, law school, medical school, or nursing school. So, in total, almost three quarters of people who found temporary work through the Baltimore Health Corp Initiative ultimately found long-term employment or an education opportunity afterward.

The initiative provides a template that Baltimore can use with other sources of federal and philanthropic grant funds. In the near term, the city is applying what it learned from the contact tracing initiative for another paid transitional jobs program called Hire UP, which is supported through the American Rescue Plan Act.

[RACHEL BRASH]

We're working with city agencies to place residents into six-month jobs with workforce supports. That's, at this point, non-negotiable. So, we're working with the Department of Public Works, with the Department of Recreation and Park, with the Parking Authority, and a number of other city agencies. So, really building on the knowledge that we gained from the Health Corps that, you know: identify the residents who need the jobs, train them, we've built in job readiness training for that, we are, you know, we have are our city agency partners. And then as with the health corps, you know, we never lose sight of what comes after the initiative.

[J.B. WOGAN]

The experiences in Washington State and Baltimore provide insights on how to handle the human, or personnel side, of contact tracing. But another takeaway from contact tracing during the pandemic is that the non-human element, the technology, could improve the public health response to an infectious disease outbreak. And by technology, yes, there are smart phone apps that might help, but what I heard about mostly was the need for modern databases that facilitate the quick collection and dissemination of public health information so that states and localities know about, and can respond to, new infections and exposures as soon as they’re identified.

[CANDACE MILLER]

Yeah, so right now, the state of data, the sort of architecture, the ability to get a piece of data from one place to the next, is dismal. It is sadly, pathetically, dismal.

[J.B. WOGAN]

That’s Candace Miller, my colleague who led the COVID-19 contact tracing partnership in Washington State.

[CANDACE MILLER]

These very old disease surveillance databases. Every state has them. They were not built for a pandemic. They're built for small, food-borne and some STDs, but pretty low rates of infection. They're not built for hundreds of thousands of people coming through.

[J.B. WOGAN]

Early in the pandemic, Candace says, it became clear that the old disease surveillance databases wouldn’t cut it for COVID-19. But by the time public health agencies were reckoning with their outdated, outmatched data infrastructure, they were in the middle of the crisis, trying to triage surging caseloads.

[CANDACE MILLER]

I think there's a real aversion to building something while you need it. Most local, county, state public health departments didn't want to build something, or didn't want to do some major repair when it was being used.

[J.B. WOGAN]

Early on, agencies might have been better off diverting some of their resources to build systems that could handle future surges, but we can only say that with the benefit of hindsight, knowing that the Delta and Omicron variants would again overwhelm case investigators and contact tracers in 2021 and 2022. To be fair, Candace says, some places did make those kinds of investments, but they were the exceptions to the rule.

[CANDACE MILLER]

I think there was always an optimism that if we just get over this next surge, we'll be okay, rather than understanding it was going to be this roller coaster ride.

[J.B. WOGAN]

At first, old databases may sound like an abstract and minor problem, especially in the context of other urgent needs we’ve faced during the pandemic, like an inadequate supply of tests or personal protective equipment or ventilators. But in public health, data inform timely action, so when the data couldn’t be shared quickly, contact tracers and disease investigators couldn’t move fast enough to contain the first cases of COVID in a community.

One very understandable reason why agency leaders didn’t replace or repair their data systems at the height of the pandemic was they wanted to mitigate worker burnout. As I’ve mentioned earlier, public health as a field has been contending with a worker shortage for decades. Contact tracers like Shan-Tia Danielle, who you heard at the top of the episode, worked long hours and often encountered hostility from respondents who weren’t receptive to public health guidance around the virus. Employers had to balance data infrastructure needs against maintaining morale and retaining personnel. Here’s Candace again.

[CANDACE MILLER]

They wanted their staff to have a time to recover. So, if there was a reduction in cases, this was a time to recover rather than to say, okay, let's hit the gas and fix something or let somebody else come and help us fix something.

[J.B. WOGAN]

At this moment, national hospitalization and deaths trends suggest that even if a lot of people are still catching COVID-19, most aren’t getting so sick that they end up in the hospital, much less dying from the disease. This might be the moment for the public health field to catch its breath and make those fixes that it couldn’t make in the past two years.

What would those fixes look like? For starters, Candace says, the disease surveillance databases of the future need to function more like an online order from a commercial site like Amazon. Contact tracers and case investigators need to know about positive cases as quickly as an Amazon fulfillment center knows about the latest online purchase of dog food.

Candace hopes the pandemic made public health officials realize they have to build data systems now to anticipate the needs they’ll have later. She draws from her experience working in Africa to expand access to electricity.

[CANDACE MILLER]

The opportunity now is to plan for the next 20 to 40 years, really. In electricity they say, you know, you've got to think about the grid that you want 40 years from now and start working towards that, and really public health needs to be thinking in that way, too.

[J.B. WOGAN]

Shelley Fiscus, at the National Academy for State Health Policy, agrees that now is a good time to address gaps in the public health data infrastructure identified during the pandemic. Taking action now would not only help with responding to COVID-19, but other diseases straining state and local public health agency systems.

[SHELLEY FISCUS]

Now with things like monkey pox, they're not necessarily following the lessons of COVID-19. You know, people are collecting data on paper forms and we're not using the existing structure for vaccine ordering and distribution that we have been using for childhood vaccines and for COVID vaccines. You know, everything's kind of being developed into parallel pathways and so, you know, really there is a lot of urgency to implement the lessons that we've learned out of this pandemic, as we move forward, not just for COVID, but for anything else that's going to come at us.

[J.B. WOGAN]

As much as the state of the data infrastructure is a concern, it’s the state of the workforce that still really worries her.

[SHELLEY FISCUS]

Right now, today, we're probably less prepared for the next pandemic than we were in 2019 because we have lost so much of the public health workforce.

[J.B. WOGAN]

The notion that we might be less prepared for the next pandemic than we were for this one is disturbing, but there are glimmers of hope in places like Baltimore, where thoughtful efforts to recruit, train, and retain the next generation of public health workers seem to be bearing fruit.

And even in cases where people didn’t transition from a temporary contact tracing job to a permanent public health position, it may be too early to tell how the work experience affects the long-term trajectory of those early-career professionals who served on the frontline during the pandemic.

When funding for Shan-Tia Danielle’s contact tracing position in Washington State ended, she moved on to work as an enrollment advisor for some colleges and as a freelance social media manager. But she hasn’t closed the door on returning to the field of public health.

[SHAN-TIA DANIELLE]

Honestly, if they called me and offered me the same job back, I would go in a heartbeat, as stressful as it was. And that's why it's so funny. You really have to be the first the right person and have the right things for this job because as stressful as it was, and this is the most taxing job I have ever had. All my other jobs are usually been physical, but mentally this is the absolute most draining job that I've ever done. And I felt low, I felt depressed and whatever. But dealing with all that, I would do it again because I had encounters that I wouldn't have had before. There are people that I was able to connect with and help because of that and my personality, that's the area that I want to stay in.

[J.B. WOGAN]

When I talked to Shan-Tia, local media in her area were already reporting on the spread of monkey pox in nearby King County, Washington. I asked if she thought the outbreak might spur the need to recruit back experienced contact tracers like her. The thought had crossed her mind as well.

[SHAN-TIA DANIELLE]

Oddly, I feel very guilty for saying I wonder if I'm going to get a call. Like, I would love to do that again because that’s something new. So, I do kind of watch my email. I'm watching the numbers to see if this becomes something that’s a little more intense, which you never want it to be.

It was a weird Catch 22 of it's great to have a job because of this pandemic, but it also sucks that we have this job because of the pandemic and if we’re dealing with something else and you know, obviously it sucks to be experiencing that, but to have the opportunity to work as part of the solution is something that I think everyone should do at least once in their life.

[J.B. WOGAN]

Thank you for listening to another episode of On the Evidence, the Mathematica podcast. I also want to thank all of the people I interviewed for this episode, Candace Miller, Shaun Stevenson, Shan-Tia Danielle, Holly Matulewicz, Brigitte Manteuffel, Jason Markesich, Jia Pu, Rachel Brash, Elinor Higgins, and Shelley Fiscus. This episode was produced by Rick Stoddard. In the show notes, we’ve provided a long list of related resources, including past podcast episodes, blogs, contact tracing dashboards, issue briefs, and other reports related to contact tracing during the pandemic. There are a few ways you can stay up to date on future episodes of our podcast. You can subscribe or you can follow us on Twitter. I am at JBWogan. Mathematica is at MathematicaNow.