When Dr. Fredrick Echols, the acting health director for the City of St. Louis, reported via The St. Louis American that the first 12 victims of the COVID-19 pandemic in the city were all African Americans, he recognized the obvious tragedy. Our health care systems are failing along racial lines. But he also recognized an opportunity, and he and his small staff of public health professionals are acting upon it.
They are doing so by following leads that emerge from contact tracing. Contact tracing is a basic tool of pandemic response. Disease investigators interview people who have tested positive for an infectious disease and ask them whom they have come into contact with during their infectious period; the investigators then trace those contacts and test them for disease.
Though the context is disturbing and potentially tragic – this is a process for telling people that they may have contracted an infectious and potentially fatal disease – the opportunity is unique. It provides public health professionals with a passport to contact the public and learn about public health. In a fragmented health care system that does not actually provide care for many people (more than a half-million people in Missouri lack health insurance, according to Timothy McBride of Washington University), there are as many gaps in our health care knowledge as there are gaps in health care coverage.
“There is a human part to contact tracing,” Echols told The American. “When an individual tests positive, we get to engage with them, and in doing that we learn about other issues. For example, we are finding people who are HIV-positive but have had no care for 10 years – and reconnecting them to medical services.”
As the city’s 12 staff disease investigators trace and interview contacts with unmet health needs beyond the pandemic, they work with the Integrated Health Network, Regional Health Commission, health centers, hospital systems and the Urban League to identify resources that may be available but unknown to the uninsured individuals.
“We treat contacts and cases as people and look to find solutions to any gaps,” Echols said.
Sometimes those gaps are immediately relevant to the immediate task at hand: slowing the spread of the new coronavirus. Fever is an indicator of contagion, so public health professionals direct the public to monitor their temperature. The virus’ membrane is destroyed by soap and alcohol-based sanitizers. So, when disease investigators interview COVID-19-positive people without thermometers or hygiene supplies or the means to acquire them, they provide those supplies to help people get through the quarantine period without infecting others.
“We tell them to take their temperature twice a day, so what do we do when they say, ‘We don’t have thermometers?’” said Franda Thomas, communicable disease bureau chief for the city’s Health Department. “The city provides them.”
This invasive access to the public reveals many more unmet health needs and many more clues as to why African Americans are suffering and dying from COVID-19 out of proportion to their population presence. As of June 18, 1,476 of the city’s 2,292 COVID-19 cases and 94 of the 144 deaths were of black people. That means 64.4% of the cases and 65.3% of the cases were of black people, when blacks form 45.9% of the city’s population.
“You hear a lot about ‘social determinants of health,’” Thomas said. “But we don’t hear about it. We come face-to-face with it.”
Poverty is a major social determinant of health. Disease investigators in St. Louis come face-to-face with poverty every day. Thomas said most of the questions that investigators are asked relate more to poverty than to health or illness per se.
She said people ask: I don’t have a doctor; where can I go, and will I be charged? How can I be medically cleared if I have no health insurance? If I have to quarantine for 14 days, will you offer any assistanceorcompensation?
The loss of income and possibly employment from quarantine is a major obstacle for disease investigators. Not only does it pose problems in getting sick people to quarantine, it also hinders contact tracing. “When we ask for people an individual might have exposed,” Thomas said, “we’re often told, ‘I don’t want to be the reason why someone won’t go to work. I’m not giving you that information.’”
Though the public health orders to slow the spread of the virus are called “stay-at-home” orders, in fact the home is the most common place where infections are spread. This poses a particular problem for parents and especially single parents.
“If you are a parent and your child has to quarantine, that means you as parent have to quarantine,” Thomas said. “If you are a single parent with multiple children, how do you isolate as a primary caretaker? These are very real-life scenarios. Contact tracing is way more than collecting names.”
This fact makes social skills like the ability to build trust, establish networks and form connections essential to controlling this disease.
“Knowing how to trace contacts is a small piece,” Thomas said. “There is another side of it that you’re not going to get from a couple of training modules. You’ve got to know the local resources and make referrals. You’ve got to be able to make warm hand-offs. You’ve got to know the dedicated staff person who can help and make an extremely warm hand-off.”
Echols said the pandemic response is educating him and his staff in the specific needs that must be met if the region is going to address the health care disparities by race that everyone has known about at least since the 2013 publication of “For the Sake of All.”
“When we talk about disparities, it’s more than numbers,” Echols said. “It’s knowing the resources that are available and being able to connect people with resources. This involves building relationships, not only with individuals in need but also with organizations that provide essential services.”
Echols is seeing the inklings of future solutions in the midst of addressing an immediate crisis. “We’re used to talking about health disparities, but things don’t seem to change,” he said. “We are starting to ask what can we do to make a sustainable difference.”
The question becomes: how can the health care system respond to the underlying social problems with the urgency of a crisis after the immediate health crisis subsides? This is not Echols’ first rodeo; it’s not his first outbreak of an infectious disease.
“We saw this with H1N1 and West Nile, too, when people were forced to seek medical services who do not typically engage with health care services. How do we keep them engaged?” Echols said.
“How do we keep organizations engaged to prioritize the most vulnerable after the situation is resolved and not go back to the status quo of treating those who have and forgetting about everybody else? That’s the system we’re trying not to repeat.”