A call is incoming. So is a tough conversation.
Over the past eight months, tens of thousands of contact tracers and case investigators have been delivering difficult—but vital—news to people who have tested positive for COVID-19 and their close contacts.
Contact tracing remains a crucial exercise as state and local public health departments try to get a handle on a virus that is both deadly and tricky to track. It’s a practice that provides insights into not just public health—but also people, their personalities, and what they’re going through. Ìý
Kara Suvada, CAS/BS ’17, a public health graduate student at Emory University and a fellow at the Centers for Disease Control and Prevention, knows from experience, having worked from May until August as a contact tracer for the Georgia Department of Public Health.
Suvada virtually joined the 30 Minutes OnÌýpodcast in October to fill us in on her summer on the phone. Not only did her experience reveal peoples’ fears amid a pandemic with no end in sight, but it also reminded Suvada, one call at a time, about the importance of appreciating context and focusing on equity as a public health practitioner.
Listen to the podcast or read the full transcript below:
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Full Transcript
Andrew Erickson: Hello and welcome toÌý30 Minutes OnÌýa podcast fromÌýÂ鶹´«Ã½Ìýmagazine. I’m Â鶹´«Ã½ magazine staff writer Andrew Erickson.
Today, in our fall 2020 episode, we’re spending 30 minutes on contact tracing.
If you’ve heard from a contact tracer this year amid the COVID-19 pandemic, then you probably know that it’s a necessary phone call—for the information that you’ve been in close contact with someone who has tested positive for COVID; for the instructions on when, how, and how long to quarantine; for advice on where and how to get tested for COVID; and for an opportunity to share updates on your symptoms, if there are any.
But it’s understandably scary. And depending on the person, leads to worry—about the possibility becoming very ill with a virus that has killed more than 1.1 million people across the globe; about the financial damage of 14 days away from work; or about the impact of quarantine on their food supply.
Since March, tens of thousands of contact tracers have been making calls on behalf of state and local health departments, trying to track and slow the spread of a formidable foe. For a story in our fall 2020 magazine, we wrote about contact tracing—its history, how it works, and the AU alumni that have taken it on amid the pandemic.
One of them is Kara Suvada, a 2017 alumna of AU’s undergraduate public health program. Now a graduate public health student at Emory University and a CDC fellow, she also spent more than three months this summer working as a contact tracer for the Georgia Department of Public Health.
In early October, Kara spoke with us about the fears that come with being a new contact tracer, the reactions from contacts that range from very kind to venomous, and the lessons a contact tracer learns about health inequities and peoples’ everyday struggles.
Here’s our interview. We hope you enjoy.
***
Andrew Erickson: Kara, thank you so much for joining me. If you can walk me through just your public health background over the last few years—what first got you interested in the field and what inspired you to start to start studying public health?
Kara Suvada: When I was a senior in high school, I was in my biology class, and I knew I was interested in biology, but I also was interested in social factors that affected peoples’ health. And then my teacher said, ‘Have you ever considered public health?’ I had never really—I mean, I vaguely knew what it was, but didn't really know what it was. And then she's like, ‘You should look into programs for that.’ She was an early mentor of mine, and then found AU’s three-year program and I applied to it and I got in with a scholarship. So I was like, ‘OK, that's a good choice.’ And then from there I’ve really loved public health pretty much from the day I started doing it.
AE: On your LinkedIn there’s just kind of a scattershot of different [public health] topics. Malaria, nutrition, stress management, health communication. What led you to kind of study those different aspects of health and how did you start to narrow down on epidemiology and certain topics related to that?
KS: I'm sort of an opportunist, so anything that comes my way that looks interesting to me, or it looks like a good opportunity or is a good opportunity to help other people, I think, is when I decide if that's a good idea or not. I think where I've narrowed it down in terms of epidemiology. I've always liked epi from when I was introduced to it in undergrad. I really liked the class and I think my goal is to be a good methodologist so that I can apply it to a number of problems. I have really good friends who have [one] subject area that they're really passionate about, like a certain disease, but I'm really passionate about a lot of different things, and I'm not as focused as them in terms of [one] disease or problem. So, I just want to be able to apply my skills to a bunch of different things.
AE: Can you walk me through March, April? I know for everyone that's, that's when COVID really started to take over, went into lockdown and schools started to go virtual during that time. What was it like being in public health school as that's unfolding, those three that three-to-four-week period before everything went online? And then the rest of the spring semester?
KS: Yeah, it was pretty chaotic. In March, our spring break was super early and they hadn't issued—you know, there was, ‘Oh, be careful. Wash your hands,’ and everything, but there was no, ‘Don't go out in public,’ that sort of thing. And my friends and I, in my program at Emory, at least, are all public health people, so we take the considerations of public health officials very seriously and follow them very strictly and so we were like, ‘What's going to happen here? And then in mid-March, our epidemiology department and other departments at the Rollins School of Public Health at Emory were like, ‘There's a chance that we could go online, if things get worse.’ And then that did happen. They took an extra week to implement their online, and the professors here did a really good job with what they had because it was such a quick turnaround. They only got a week to transition their entire curriculum from being in person to online, and our work study jobs had to transition to being completely online. So it was just a huge transition. And I think for me and a lot of other people is just was like, ‘Okay, let's finish the semester.’ Just hope that no one in your family gets sick, and none of your friends get sick. And I think, for me at least, that was the first couple of months—mostly just, ‘Don't leave the house, unless you have to, follow the follow the science and public health guidelines, and finish out this semester.’
AE: Did it start to shape some of your classes—the epidemiology classes you're taking? Just to have this live event happening, this disease that is impacting and killing so many people, how did that shape discussions in your classes, and what was that like as that was unfolding?
KS: Yeah, it definitely started to shape classes at the end of the semester, I would say a lot more this semester because our professors had a lot more time to prepare for that. I'm a teaching assistant for a social epidemiology class, and so we sort of tailored some of the materials to be COVID related. So I think this semester there’s more of that. Last semester, it was incorporated because, you know, what else are going to talk about at a certain level? Of course everyone was interested in it and interested in helping out. There was definitely incorporation of COVID in the early days, but I think especially over the summer, as there was time to sort of develop materials—and I will say almost everyone I know has been involved, because either you transitioned to working on COVID right away or it impacted your work somehow, and you have had to navigate around it. There's no, like, ‘Oh, I don't have anything to do with that.’ It's either one or the other, and in some way you're helping with the response.
AE: Over the course of spring semester, when did the possibility of learning to be a contract contract tracer come up? What were your considerations going into that, and how much had you heard about it in your public health study prior to taking it on?
KS: The possibility of becoming a contact tracer came up probably in April, at some point, I actually am also a fellow at CDC. I have not updated my LinkedIn yet because I haven't had time, but it will get on there, at some point. It came up maybe in April. The Georgia Department of Public Health reached out to Emory and was like, ‘We need a lot of students to help this summer.’ I knew that was an effort that state level governments were doing and all the students were aware of that. And so I thought to myself, ‘You know, I think this would be a really good way to make a difference and to be helpful.’
I knew that I wanted to help on the response summer because I knew when I got back to classes that I wouldn't be able to do as much. I think there's like a time and place for every field to do their part, and I knew this was public health’s turn to really do its part. That was my motivation for becoming a contact tracer. A mentor of mine from a previous job also encouraged me to do it and I take her advice very seriously. So I was like, ‘I think you're right,’ and I wanted to do it as well. How the application process worked is there was sort of a special system with Emory and the Georgia Department of Public Health. They knew that they wanted students and Emory has a really good relationship and a good rapport with the [Georgia] Department of Public Health, because we have a lot of people who intern there anyway. You just went into the state government portal, applied with your resume, and they let you know if you were accepted or not. I actually had taken a different training before that, just to see if I was up to it because I knew it was fairly demanding. You have to talk to people for the hours that you're doing it. After I took the training, I was like, ‘Yeah, I think I can do this.’
AE: What about it was new when you went through the training? The one you did on the side, in addition to the one the Georgia Department of Public Health had? What were some things that were new about it? What surprised you initially about what the process entailed?
KS: You have to ask a lot of sensitive questions. And I think that's what that what gets people. A lot of times you get their number from public records and people don't know that. I didn't know that before I started the training, and a lot of people, a rightly so, well not really—in some situations, it's rightly so that you might not trust the government because of historical wrongdoings to certain communities like Black populations or Native Â鶹´«Ã½ communities. I understand that because the government has done them wrong a lot of times, so there's a big disparity there and I understand when people are not as trusting to pick up the phone. Anyway, we get the numbers from public records and then you call people, but you have to ask them very sensitive questions like, ‘Who have you been in contact with?’ and ‘What are your symptoms?’ and ‘Have you been to work recently?’ and ‘Do you work?’ People have to tell you if they're on disability or not. There's just a lot of very sensitive questions. Oh, ‘What's your birth date?’ A lot of people didn't want to give that out because they're like, ‘Why do you need that? Why do you need my age?’ We also asked about comorbidities and a lot of people don't want to disclose that they have COPD or diabetes.
AE: What was the initial workload like? Your setup? Are you making calls from home and how many hours a week were you working off the bat?
KS: I worked in a more rural, northern district of Georgia. I work from home, but I had to drive up there to get my laptop and phone because you don't use your personal phone because, you know, you would be bothered at all hours of the day, which makes sense because that's your job. But you sort of get that. I was set up for 20 hours a week because I actually also worked as a fellow, as I mentioned, with the CDC. I did that during the day and then I did nighttime contact tracing and I did one weekend day, so I took Saturdays off. But it was 20 hours a week and basically you got your laptop and your cell phone and you went through, I would say it's probably between six and eight hours of training, maybe a little more because you have to go through the typical sexual harassment and conduct and all of those sorts of trainings for government. Then you had to do these special contact tracing and talking to people trainings. Basically, what you do is get trainings on what's called Google MTX, which is a contact tracing system from Google and it loads in the person's information.
I was a contact tracer, not a case investigator. A case investigator is someone who calls the person who tested positive and asks them about who they've been in contact with. The contact tracer is the person who calls the contacts of the case. I was the person who picked up the phone and called someone and said, ‘Hi, you've recently been in contact with someone who has a confirmed case of COVID. Were you aware of that?’ And then if they were aware of that, then I just went into a symptom intake asked about their birthday, asked how they were doing and any other concerns that they had. If they weren't aware that they had been in contact with someone, then we were usually especially careful not to reveal that person's identity because it was probably the case that that person didn't want others to know that that they had tested positive. Sometimes it was like a husband or wife. I remember there were a bunch of calls where I pick up and was like, ‘Hey, are you aware that you've been in contact with someone who has COVID?’ And they’d be like, ‘Ha, that's my husband.’ So, some people know and that's it. That's an easy conversation.
AE: What would you say the breakdown was in terms of people who knew versus the percentage [that didn’t]?
KS: I'd say most people knew.
AE: Really?
KS: Really, yeah. And there were times that people didn't—if it was an employer-related outbreak at a restaurant or fast-food chain or a factory. But if it was family or a friend, almost always they knew already.
AE: For you, what was it like calling strangers? I mean, like you said, you're dealing in very difficult information and you're asking some pretty tough, pointed questions. Sometimes people are reluctant to answer. Was there an initial nervousness that came with that? Were you pretty comfortable with balancing that with the mission and it was OK?
KS: At first I was definitely nervous. I remember the first day I did it, I was like, ‘Am I actually qualified to do this?’ But then, you do get used to it and they said that. The people who trained us, the great people at the state health department, they said, ‘You'll be nervous at first, but then you'll get into a rhythm and you'll learn how to more readily deal with talking to people,’ and that is completely true. At first, I was nervous, just because it's a sensitive question to ask about a novel disease and who they've been in contact with and what their symptoms might be. And, frankly, sometimes it's depressing, too, because the person is very sick. You get used to it and you sort of separate your emotions from it, like if someone is hostile towards you or something. You just have to say, ‘You know, I don't know what they're going through,’ or whatever, and ask your questions because the mission is to help slow spread, right?
AE: Were people generally pretty good about picking up the phone and did that change over time? Talking to a number of people for this story, they mentioned that early on, maybe, April, May, even into June, people weren't as good about it, just because maybe there wasn't as much marketing around it. But then as public health departments got better about publicizing certain numbers or, ‘Hey, you know, make sure to look out for these area codes,’ or things like that, then people got better. What was your experience with that? And what did you see in terms of responsiveness from people?
KS: I would for sure agree with the statement you just made. I think that at first, people were like, ‘What is contact tracing? Why are you calling me? I've never heard of this. Which is fair. And then as time went on, I think people got a lot more comfortable. And as the message was spread that, ‘It’s OK, the health department will contact you if you've been in contact with someone who has COVID.’ Or, ‘If you have COVID yourself, you will be called by the health department.’ There were a lot of health departments at the local, state, and even at the CDC level, [with information] dissemination campaigns of, ‘Pick up the phone, do your part,’ and so I think that campaign messaging worked to a certain extent as it got throughout the summer. And, you know, once you start knowing people who have tested positive or have been in contact with someone who tested positive, they tell you, ‘Oh, it's fine. They just call to ask you a couple of questions.’ Whereas if you're the first person in your social bubble that is getting this call, that’s probably a lot more nerve-wracking than knowing someone who says, it’s fine, typically it’s a five -to-ten-minute phone conversation and it's no big deal, that they're just doing this to help you take the best action like ‘Where should I get tested? When should I be calling the doctor, if my symptoms get too severe?’ And the quarantine guidance on how long they should be isolating at home. Or, quarantining at home, rather. Isolating if you’re confirmed [positive for COVID-19], quarantining if you're a contact.
AE: And how wide was the range of reactions from people? Did you sometimes get people who were very gracious and people were very angry, back to back? What was it like managing that? And what were some of the experiences you had just in terms of how people handled the information and/or listened to it?
KS: I would say it was from zero to 100 on that level, and there were some people who were like, ‘You're the most helpful person I've talked to during this pandemic,’ and ‘I wouldn't have gotten tested without your help,’ or ‘I didn't know the tests are free,’ which they are. Well, I don't want to generalize, but in Georgia, at least, they are free if you go to the state health department. There were people who were asking questions and making sure that they were following guidance exactly to the to the recommendation of the health department, and then you had people who would call you names, yell at you, and ask why you had their number. And, you know, call COVID a hoax. I mean, the range was wild. The range was wild.
AE: When you talk to people and they talked about what they were going through or some of the difficulties they had what, what were the biggest fears? I imagine it can be pretty jarring as a contact tracer to talk to somebody who's sick or suddenly developed symptoms. I imagine people talk about certain financial issues. I imagine people are afraid of being found out, so to speak, for going out in public or doing something that they shouldn't be doing based on recommendations. What was the kind of range of fears people had and what was it like for you to see that firsthand?
KS: Yeah, the biggest fear, typically, especially in middle-aged and older adults, was getting sick. It was pretty sad sometimes to talk to people about that because it is so scary and you have nightmares about your own parents getting it and stuff. So, that was definitely the most jarring conversation to have. And I think the thing that people were most scared of was developing an illness that would send them to the hospital or make them ill to a point of not making it through. I'd say the second-biggest concern, especially among younger people, or people with small children, was financial stuff. Sometimes we helped people in terms of finding a food pantry or taking off work. We had a system where if someone needed to quarantine, we could send a letter to them so that they could give it to their employer so that they wouldn't get in trouble. I'd say that was a that was a big one, especially from 18 to 20, 25 to 30-year-olds, that was a big concern. Usually, it was like, ‘Well, how am I going to take off work? How am I going to quarantine for 14 days when my boss is not going to accept that? And then we're like, ‘Oh, we'll send you a letter from the state saying that like you need to, so I think that was the second biggest concern, after obviously the physical illness of it, and the mental health [impact] of not knowing if you would develop symptoms or not. Because sometimes you'd call people and you don't know if they're going to develop symptoms or not because it's two or three days after they've been exposed, and so it's a wait and see sort of situation and it’s high tension because sometimes people are like, ‘Well, will I develop symptoms?’ People would ask, ‘Will I develop symptoms? Will I get really sick?’ And you don't know the answer.
AE: What were some of the most common questions you got from folks?
KS: Some, if they hadn't developed any symptoms, it would be, ‘When would I start seeing symptoms?’ And, you know, we'd give them a range. What symptoms were of COVID-19, when could they return to work. Let me think. Some people asked when a vaccine was coming. I'm like, ‘I wish I knew myself.’ Let’s see, what else, other common questions. Some people asked about resources, in terms of food pantries and food security and that sort of thing. The number for the testing hotline and where to get tested. That was another huge one was where to get tested and who would return the fastest test. We don't know the answer to who would return the fastest test, but that was another huge question was, ‘Where can I get the fastest test possible?’ A lot of people also just wanted a free test, and the state health department provides free testing. So I'd usually refer them to state health department.
AE: I know it varies by state. Some states have a system where the contact tracer will call that individual person every day or every other day for 14 days. There are some states that have text messages. In Georgia, what was the system? And was the first time you talked to someone the last time you talked to them, or did you have multiple contacts with some people?
KS: So you'd call them. And if you got them enrolled in the text messaging system, that was the last time you contacted them unless they contacted you because you always left your number in case the individual called for questions. But if you got them enrolled in what we call SMS or text messaging symptom monitoring, then we would leave them alone. At first we started to ask, ‘Oh, would you like us to call you every day? Would you like text messages?’ But we didn't have enough people to support the capacity of calling people every day. And so we only did that in cases where the person only owned a landline or it seemed like it was really necessary for us to follow up with them via phone, because there was no way that they would reply to the text messages. Otherwise, it was strictly follow-up via text messaging and we'll contact you again if they didn't respond. But if they were responsive every 24 hours—which means, every 24 hours you'd get a text asking if you had symptoms—we would otherwise leave that person alone.
AE: I’ll ask a really broad, overarching question. What would you say you learned about yourself throughout this process? And what would you say were your most important takeaways about public health from being a contact tracer?
KS: Great question. In terms of public health—that we should always be advocating for more funding for public health because we are we are working under constrained resources a lot and I think that public health has gotten under the spotlight, both [to be scrutinized] and sort of like [placed in] a positive light as well. And now I think the general public knows more about who an epidemiologist is and what public health really does. I would say that is really encouraging and inspirational to see how many people in state health department capacities or local health department capacities are working under such constrained resources. And then I would say no one person is the same. That's the other thing I learned, is that everyone is different when you are calling people on an individual level like that. It's never good to generalize and you have to take every person's context into consideration when you're talking to them about such a sensitive and emotional and just very altering topic like COVID.
AE: How did this shape your outlook on contact tracing? And what would you say you learned about, you know, how, in an ideal world, how it can be done, what its importance is in [fighting] infectious communicable diseases? Just the general importance of why we need contact tracing?
KS: Contact tracing is really important and necessary and, you know, pre-COVID, contact tracing was used for—is used and was used for many other diseases like foodborne outbreaks or STIs, sexually transmitted infections. And so it wasn't a new concept of public health, but the scale on [which] we have attempted to implement it in this country is like nothing we've done before, to my knowledge. It's just so necessary because it's how you know who is sick and where. I know, for example, in other countries that it's worked a little bit better just because of top level support for the activity and a more centralized effort to the process. Like I know in, I think it's Taiwan, for example, they use text message monitoring, too, but you're just fully supported if you have to go into quarantine and people follow guidelines and trust public health and stuff like that. I'm not saying we should compare ourselves to Taiwan, because there's two completely different countries and contexts, but contact tracing is what helped Taiwan to get back to such a low level of cases per day. I use the example that, a month ago, they had a 10,000-person concert, and no one was infected from it. No one had it.
AE: Having gone through this experience and been a contact tracer for a few months, what advice would you offer to someone who, they’re just going about their life, and then one day a number pops up on their screen that says COVID team or has an area that they don't recognize. What would be your recommendation to somebody who is now involved in this process, whether they like it or not?
KS: I'd say pick up the phone because the person on the other end is not trying to do anything to you that will hurt you in any way. They're trying to inform you about something that will be affecting your life. It's everyone's duty to slow the spread and it's harder for some people rather than others. I have the distinct privilege of being able to work completely from home. There are other people that that is not possible for and it disproportionately impacts women and people of color and people in a low socioeconomic status. So it's very different for many different people, but picking up the phone will help regardless of your situation because that person can offer you advice in the context that you're in and we'll send you or get you the help that you need to get through either having been in contact with someone with COVID or if you have COVID yourself. Yeah, the public health department is only trying to do good for you.
AE: Yeah, and you touched on a little bit at the beginning about how COVID it and talking about the context has shaped your fall semester. But what's it like now at Emory in what you're studying? How has COVID kind of shaped the context of what you're learning?
KS: I mean, it impacts everything. To and to be completely transparent I I stopped contact tracing in the middle of August to go back to class because I had to balance my classes because I'm still a fellow at CDC and I couldn't do all three. So I was a contact tracer from May until mid-August. And there are many of my colleagues who are still contact tracing and it’s very noble. I'll say this, it's shaping almost every class. There's no class where we don't talk about COVID. It's either in terms, if you're in a methods class, it's, you know, how do you measure XYZ—sensitivity and specificity of COVID tests? If you're in the class I TA, social epidemiology, we talk about how COVID is disproportionately impacting different populations, because of the inequitable distribution of the social determinants of health. So it ranges, but whether you're in a class about vaccines and it's a very clinical look at COVID and how we're going to manufacture and distribute a vaccine to how is it affecting people in terms of social factors, there's no realm in which COVID is not a part of the discussion.
AE: And as you look you know toward the future, how would you say you would most prefer to apply your epidemiology background? I know you said you have a lot of interests, but what would you say is your goal as you look toward post-Emory, what you want to do?
KS: Great question. Still kind of deciding that as we as we talk. Right now I work for, in addition to being an ORISE Fellow at CDC, I work at the Emory Diabetes Research Center. I worked there last year and I'm working on my thesis with a couple of really amazing scientists there right now. I really like thinking about social epidemiology and chronic disease prevention. Of course COVID is an infectious disease and I'm, to the extent that we all need to be helping out on it, I'm interested in COVID stuff, too. But if you were to ask me what I've honed my interests in over the last year or two, it would be chronic disease prevention and social epidemiology.
AE: I think those were all the questions I had for you. Is there anything else you wanted to add about your work or public health or being a contact tracer?
KS: The only thing that I would emphasize is that COVID is definitely impacting people differently depending on their situation. It's important for us to understand in public health that your mindset has to be of equity and pushing justice and equity. Otherwise, you're not doing the job that you could be doing. COVID, like many other diseases, disproportionately impacts people who have been historically disadvantaged and are currently disadvantaged because of the inequitable distribution of social factors. So, one thing that it really has driven home for me the whole pandemic is that inequity drives unequal morbidity and mortality.
AE: Very well put. Well, thank you so much for taking the time. I really appreciate it, and best of luck as you finish out fall semester.
KS: Thank you so much, Andrew. I really enjoyed talking to you, and best of luck to you as well.
AE: That was the Fall 2020 episode of theÌý30 Minutes OnÌýpodcast fromÌýÂ鶹´«Ã½Ìýmagazine. Thank you so much to our guest, Kara Suvada, for virtually joining us and chatting about her experience as a contact tracer.
You can find our first two podcast episodes, with Social Justice School founder Myron Long andÌýSchool of Communication professor Saif Shahin, and subscribe in theÌýÌýor in the Google Play store. And a full transcript of the show is available on our website atÌýamerican.edu/magazine.
Keep an eye out for our fall 2020 magazine, which hits mailboxes soon. And we’d love to hear from you. Let us know what you think about the magazine by emailingÌýmagazine@american.eduÌýor chatting with us onÌýTwitterÌýorÌýInstagramÌýat @AU_Â鶹´«Ã½mag.
Thanks for listening, stay safe, and remember, pick up the phone!
We’ll see you next time.