Biden’s plan for an army of disease trackers faces long odds

A raging pandemic and a gridlocked Congress could upend President-elect Joe Biden’s plan to hire 100,000 public health workers to trace Covid-19’s spread, despite widespread agreement it’s needed to finally end the crisis.

Contact tracing will be essential even after Covid-19 vaccines become widely available, because not everyone will get shots and scattered outbreaks will continue to ripple across the country. Quickly identifying who’s been exposed to people with infections can guide efforts to stamp out new hot spots and break chains of transmission.

State and local health departments had fewer than 2,000 workers carrying out contact tracing before the Covid-19 outbreak. A hiring burst over the summer wasn’t nearly enough as once-isolated outbreaks blanketed the country. But building a federal army of disease trackers could cost billions of dollars — and won't come in time to slow the current wave that's led to more than a million new U.S. cases a week and left health officials largely in the dark about where the virus is spreading.

“Contact tracing works best and is most effective in settings where there isn’t the level of rampant transmission that there is now,” said Nicole Lurie, a former assistant secretary for preparedness and response at the Department of Health and Human Services and a public health advisor on Biden’s campaign. “There have to be measures to tamp down the level of the virus before it can be effective.”

States are so overwhelmed that earlier this week the Centers for Disease Control and Prevention released recommendations for who tracers should prioritize if the severity of the pandemic leaves them swamped with cases.

Yet Biden’s plan for a public health corps, which has been projected to cost $3.6 billion, would immediately run up against a deadlocked Congress that is nowhere close to passing a new round of pandemic aid — and, potentially, a GOP-controlled Senate reluctant to release more funding for state and local health departments and opposed to a stronger federal role in the pandemic response. A bill from close Biden ally Sen. Chris Coons (D-Del.) that mirrors Biden’s pitch for a national contact tracing corps has languished, with no Republican cosponsors.

Still, infectious disease experts say a plan like Biden’s is long overdue, particularly because the U.S. went into the pandemic with a piecemeal contact tracing workforce that had been decimated after more than a decade of budget cuts. With tens of millions of people out of work from the pandemic, the plan could do double duty as a public health and jobs program.

Scaling up now, even while infections are out of control, could also help officials better understand where and how outbreaks are happening — allowing them to surge resources and eventually vaccines to particular areas.

“It’s like you have a bowl of spaghetti and you're trying to follow with your eyes one strand of it. It becomes an impossible task,” said Dr. Celine Gounder, a member of Biden’s pandemic advisory board. She said she still backs some degree of contact tracing “less with the idea that it's for the specific people involved in that chain, but rather to better understand how transmission is occurring in the community more generally … so it does still inform policy.”

Public health leaders who have met with Biden’s team are also urging that the 100,000-strong corps be made permanent, so it can be deployed to work on other infectious diseases once the pandemic is over.

“Biden has talked about ‘building back better’ and that needs to be true for public health as well,” said David Harvey, the executive director of the National Coalition of STD Directors. “We want them to remember that we’re in this for the long haul.”

Biden’s more nationalized strategy would mark a shift from the Trump administration, which left contact tracing — along with most aspects of the pandemic response — to the states, and did little to educate the public about how it worked or encourage them to participate.

Misinformation and conspiracy theories flourished due to the information vacuum, and public cooperation with tracers fell dangerously low. Biden’s team hopes to overcome some of that mistrust by hiring members of minority and underserved populations to do “culturally competent” outreach in their own communities. But Marcus Plescia, the chief medical officer of the Association of State and Territorial Health Officials, says it won’t work unless it’s paired with another of Biden’s pledges — to patch the country’s weak social safety net with more economic aid for low-income workers who lack sick leave.

“If you’re asking people to quarantine, they’re going to be really reluctant to do that if they’re living paycheck to paycheck,” he said. “Without more policies and support for people in that situation, it doesn’t matter how many contact tracers you hire.”

Now, as cases surge and hospitalizations hitting daily records for more than two weeks, the already strained workforce has been completely overwhelmed, and forced in many cases to pare back their efforts.

“A lot of states have started to look at how to reprioritize certain populations or situations that are particularly high risk, and reframe what their goals are,” Plescia said. “There are only a handful of places that have the capacity to even begin to deal with the surge in cases.”

Alaska on Monday became the latest state to ask residents who test positive for Covid-19 to tell their own close contacts because contact tracers in the state can’t keep up — joining officials in Kentucky, Missouri, North Dakota, Wisconsin and several other states that have done the same.

States like Utah and Washington are relying on the National Guard to boost their tracing efforts, but federal funding for that work could disappear at the end of the year.

New Mexico Gov. Michelle Lujan Grisham, who's in the running to be Biden's health secretary, on Wednesday signed legislation that provided the state with $10 million in new funding for additional contact tracers.

With many states not able or willing to invest as much, the CDC advised local health officials to triage and focus on calling people who have tested positive within the last six days, members of their immediate household, the elderly and vulnerable groups like people with health conditions or jobs that make them more susceptible to the virus.

The current surge of cases has even left some wondering whether Biden’s call for 100,000 contact tracers is enough to meet the moment.

Biden’s plan envisions the federal corporations potentially expanding to “many more” than that baseline number.

According to a calculator created by The Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University, California alone would need more than 60,000 new contact tracers based on current virus levels.

“The bare minimum is 100,000 — we probably need closer to 300,000,” said Harvey.