Proceedings of a Workshop
Contact Tracing and the Challenges of Health Equity in Vulnerable Latino and Native American Communities
Proceedings of a Workshop—in Brief
The National Academies of Sciences, Engineering, and Medicine’s Roundtable on the Promotion of Health Equity hosted a public webinar titled Doing It Right: Contact Tracing and Health Equity on July 30, 2020. The webinar focused on the role of contact tracing for vulnerable groups, in this case, Native Americans and Latino communities, during the COVID-19 pandemic. This webinar builds on a prior webinar organized by the roundtable titled Pursuing Data on COVID-19: The Health Inequity Multiplier, which focused primarily on Black communities.1
There is ample evidence that communities of color are experiencing significantly higher rates of infection and significantly higher mortality rates when compared to white Americans (Selden and Berdahl, 2020). As states and communities emerge from stay-at-home orders and reopen, testing and contact tracing are important tools to use in heading off future outbreaks of COVID-19.
It is critical that contact tracing efforts are executed in ways that are appropriate to those communities experiencing a greater burden of COVID-19 (Waters, 2020). In some cases these efforts should take into account the distrust some communities have in health care systems and providers. Other issues relevant to contact tracing include language, cultural competency, health literacy, stigma, and privacy concerns, particularly in multigenerational households. Furthermore, contact tracers may identify individuals who lack access to care and/or health insurance, or the supportive services needed to isolate if they test positive, and some individuals will be residents without documentation.
Recruiting and building a new cadre of contact tracers should meet the immediate goal of addressing the pandemic, but attention could also be paid to building a public health infrastructure in communities that supports health equity.
Winston Wong, chair of the roundtable, opened the session by outlining the objectives for the workshop.
- Provide a brief overview of contact tracing;
- Discuss contact tracing strategies that promote health equity in public health agencies representing highly diverse counties;
- Describe the contact tracing challenges in the Latino community, including trust, residents without documentation, language, and potential solutions to mitigate these challenges; and
- Learn about contact tracing challenges in highly impacted Native American communities.
A panel of three presenters responded to a series of questions from members of the planning committee. The panelists were Tony Iton from The California Endowment, Gira Ravelo from Florida International University, and Amy Dixit from the Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC).
1 For more information, see https://www.nationalacademies.org/our-work/roundtable-on-the-promotion-of-health-equity (accessed November 19, 2020).
CONTACT TRACING, CHALLENGES FOR PUBLIC HEALTH AGENCIES, AND THE ROLE OF PHILANTHROPY
Iton was asked to provide a brief overview of contact tracing and its use in controlling the COVID-19 pandemic. Iton made the point that at a time when there are few tools to help protect vulnerable communities from the spread of the virus, contact tracing is a “key tool.” The objective of contact tracing, he said, is to identify people who have come into contact with someone who has tested positive for COVID-19. This should prevent or slow the spread of the virus within a community. The hope is that the cycle of transmission of the virus will thus be interrupted.
There are, according to Iton, five key steps in contact tracing. First, identify individuals who have come into contact with a confirmed case. Second, contacts must be informed of their potential exposure and that they are at risk of having acquired the virus from someone who tested positive for the virus. Third, contacts must be referred for testing. Fourth, contacts must be monitored for symptoms of COVID-19. Fifth, contacts must be connected to services they might need (e.g., a place to quarantine2 away from one’s family; access to food while in quarantine).
Iton noted that the process is not always simple. Contact tracing can often raise ethical and trust issues, making the process more complex. Communities of lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals, individuals experiencing homelessness, and individuals who were formerly incarcerated may be examples of communities where specific efforts to build trust are needed, particularly when they are approached by an individual representing a government agency.
Another challenge is the process of quarantining, explained Iton, which involves asking people to essentially disrupt their lives and deal with the complicated logistics of living in isolation. These challenges include finding appropriate housing and access to food and missing work.
Wong asked Iton to focus on his previous work as the head of the Alameda County Public Health Department in California and to briefly discuss the challenges public health departments encounter when implementing contact tracing at the county level.
First, Iton noted that counties are struggling with insufficient testing capability. This includes a limitation on the number of tests that counties are capable of performing and slow laboratory throughput, which result in delayed results of limited value. Iton said that across the county, it may take 4–10 days to get results.
The second challenge described by Iton is that the pandemic is disproportionately affecting populations already dealing with health and socioeconomic disparities. Appropriate contact tracers should be hired to reach those populations, Iton noted. California is trying to recruit and hire 20,000 contact tracers. He added that this can be seen as an economic development opportunity for those communities heavily affected by COVID-19, given that contact tracing jobs are good jobs with benefits, paying $25–$30 per hour. The goal is to help the contact tracers tap into a career trajectory that offers a career ladder in either health care institutions or public health agencies.
The third question Wong asked Iton centered on the role of philanthropy or other public–private partnerships in conducting work around contact tracing. Iton explained that The California Endowment has brought together 10 large foundations in the state and they are pooling their resources. These resources have been offered to the state to help complement and extend state resources. The group is also making efforts to ensure that the contact tracing workforce is culturally and linguistically diverse.
EFFECTIVE CONTACT TRACING FOR LATINO COMMUNITIES
Ravelo answered questions from roundtable member Mario de la Rosa about how to implement contact tracing with Latino communities. In response to a question about lessons learned from her experiences working with Latino communities, she first explained that both Miami-Dade and Broward Counties in Florida have high numbers of COVID-19 cases and that the Latino communities in these two counties are among the hardest hit in the United States.
Ravelo explained that to work with vulnerable Latino communities, the issues of trust and culture must be addressed in order for any contact tracing program to be effective.
As Iton mentioned, testing is an important component of the contact tracing process. Ravelo pointed out, however, that many Latino individuals would only get tested at sites where identification is not required. This points out the importance of community leaders spreading the word within the community that it is safe to get tested. She emphasized that this is why trust is so important.
If promoting testing is challenging, contact tracing is even more difficult, she said. For immigrants, particularly those who lack documentation, there is fear, especially if a government agency is involved in collecting information.
2 Quarantine keeps someone who might have been exposed to the virus away from others. See https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html (accessed September 18, 2020).
Ravelo explained that one community leader said to her that “the fear of being deported is greater than any other fear that they could be facing.” In addition, for some, the health consequences of COVID-19 are less worrisome than the personal and economic impacts, she reported. Long-standing relationships with trusted community leaders must be a part of any contact tracing efforts.
Ravelo was asked to identify community characteristics or values that could be assets in contact tracing. She explained that Latino community members maintain a strong sense of “collective community.” These feelings of collective community include pride in their Latino culture and dedication to one’s family. Therefore, community leaders can appeal to the sense of collective community to promote testing and contact tracing.
CHALLENGES TO CONTACT TRACING IN INDIGENOUS COMMUNITIES
Dixit is an epidemiologist with AASTEC. Roundtable member Rachel Fabi asked Dixit about the challenges many Native Americans who live in multigenerational homes may have when asked to quarantine or isolate from family members and the associated privacy concerns.
Multigenerational homes are a resiliency factor for Native American families, Dixit said. Living with grandparents and great-grandparents provides opportunities to pass down cultural traditions and languages. On the other hand, living in a multigenerational household has also led to higher secondary infection rates among family members, she added.
Fortunately, Dixit explained, tribal and state governments recognized this as a potential problem early on and worked together to establish alternate care sites around the state. The sites provide family members with safe spaces to either recover from their infections or to safely quarantine away from family members who are themselves isolating. Privacy concerns are very real for multigenerational families sharing the same household, she said. Because of this, all contact tracing is conducted by cell phone to allow for a bit more privacy (as opposed to a landline). Text messaging is also an option.
Dixit was asked about reaching tribal members who live in remote areas of reservation lands and the challenges in reaching those members for contact tracing. Although she noted that cell phones could be used, cell phone coverage in rural areas can be spotty. Additionally, many rural tribal members are reluctant to answer a call with an unrecognized phone number. Dixit explained this is why it is so important to create relationships with the communities served and to utilize accepted networks in order to reach this population. For example, this could include tribal program staff, community health workers, or public health nurses.
Additionally, Dixit said several Native American communities have established either an Incident Command System or other form of an emergency response system, and are using these systems to respond to the pandemic. These systems work across departments within the tribal community and are used in a variety of ways from distributing food to setting up laundry services during an emergency response. These systems can be helpful when working with geographically remote tribes.
A final issue discussed by Dixit focused on understanding the processes of coordination across state, local, and tribal governments, particularly around the distribution of resources and the responsibility for contact tracing. Dixit explained that contact tracing was a highly coordinated endeavor and in the case of their region, the Indian Health Service’s (IHS’s) Albuquerque Area office and the New Mexico Department of Health partner with AASTEC to handle the coordination.
She said that trust and good communication are critical for working with and across the different entities. She also emphasized that tribes are sovereign nations; thus, tribal leadership makes the ultimate decisions.
TRUST AND CONTACT TRACING
All three speakers emphasized the importance of trust in engaging communities for contact tracing. Iton noted that the process of contact tracing can often raise ethical and trust issues, making the process more complex, particularly for marginalized communities. Ravelo explained the critical role of trust in Latino communities, especially for undocumented residents. Dixit described the importance of trust between Tribal health staff and IHS and state health departments.
ADDRESSING SYSTEMIC RACISM AND CONTACT TRACING
Panelists were asked to discuss how contact tracing strategies can be developed to address issues around systemic racism. Iton said that contact tracing alone cannot undo systemic racism, but by being intentional about the contact tracing workforce and recruiting from the most impacted communities, progress can be made. At the same time, he said, attention must be paid to what Iton called “policy violence.” He defined policy violence as the absence of policies in the face of abject need. For example, this could include a lack of policy regarding living wage jobs or a lack of policy
to access adequate housing. Iton called this failure or lack of policy “state sanctioned violence.” At a minimum, he said, there should be efforts to repair some of these injuries, and one way to do that is to hire contact tracers from vulnerable communities.
Dixit noted that a critical factor for contact tracing in Indigenous communities is the ability to utilize tribal languages. It is also critical that Indigenous data sovereignty principles be honored, as this is an important way to ensure that data remain in the community itself. Finally, working with tribal leadership is essential. There are established systems of governance in each tribe, and this must be recognized and respected.
USE OF TECHNOLOGY AND CONTACT TRACING
The potential of technology-based contact tracing, particularly its use in communities of color, was discussed. Iton noted that because of the privacy concerns, care must be taken with its use. However, technology can be useful in checking in with individuals who are quarantined, he said; otherwise, this process is labor intensive for health departments. The telephone check-ins are automated, with people responding to a set of standard questions. The answers are then automatically populated to a database and flagged for follow up by the health department if someone reports showing symptoms of infection.
As previously discussed by Ravelo, using technology-based contact tracing is difficult in the Latino community, due to it “being a community that tries to basically stay undetected.” She also noted that there has been misinformation surrounding contact tracing and the use of technology. For example, there has been a rumor circulating that when an individual is tested, a chip is implanted so that their location can be traced. Such misinformation needs to be countered. This is why it is important to include community leaders in the process so that they can address misinformation and its sources, she said.
Dixit again mentioned that her organization is using a text messaging system from the Centers for Disease Control and Prevention. This system allows those who are quarantining to still be monitored for symptoms. She also noted that texting does bring its own challenges and that “a lot of people, especially older people, just prefer phone calls from us.”
CONTACT TRACERS AND SOCIAL SERVICES
Contact tracers may also need to be trained to facilitate connections with social services as much as with informing individuals about quarantine, risk reduction, and disease containment. Ravelo described a project she was part of that trained community leaders to become community health workers to work with more traditional contact tracers. The community leaders liked the training. At the same time, she said that in her experience, contact tracers might feel overwhelmed by the various demands of the job. Ravelo proposed that a more effective model would be to have a parallel position for a case management community health worker who would work with more traditional contact tracers. The case managers could assist in providing the services needed by individuals who are identified by contact tracers, such as housing and food.
Dixit explained that her organization assigns certain contact tracers to individual communities so that those contact tracers can focus more on the needs of the community and the services offered in that community. Iton described the difference between “warm” and “cold” handoffs for additional services. A warm handoff means there is a direct transfer to another person; he noted that California’s federally qualified health centers are good at doing this. A cold handoff is simply giving the individual a list of referrals. Obviously contact tracers are urged to carry out warm handoffs to the extent possible.
In closing, each panelist was asked for their two most important takeaways for audience members. Iton suggested that first, do everything possible to match the demographics of the contact tracing workforce with the demographics of the epidemic itself. He also noted that contact tracing is not a new tool, it works, and it is possible to see the impact on the epidemic locally or regionally.
Ravelo said that by far, the most important aspect of contact tracing is trust and the use of community leaders who have the trust of community members. It is essential to take into account the culture of the target population and the strengths and weaknesses of the culture, she added.
Dixit highlighted the importance of transparency and that a respect for Indigenous sovereignty is critical. ◆◆◆
Selden, T. M., and T. A. Berdahl. 2020. COVID-19 and racial/ethnic disparities in health risk, employment, and household composition. Health Affairs 39(9):1624–1632.
Waters, R. 2020. Community workers lend human connection to COVID-19 response. Health Affairs 39(7):1112–1117.
DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Kat M. Anderson as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Kimberly De La Cruz, University of Pennsylvania, and Darla Thompson, American Association for the Advancement of Science. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSORS: This workshop was partially supported by Aetna Foundation, The Colorado Trust, Health Resources and Services Administration, Hogg Foundation for Mental Health, The Kresge Foundation, and U.S. Department of Veterans Affairs.
For additional information regarding the workshop, visit https://www.nationalacademies.org/our-work/roundtable-on-the-promotion-of-health-equity.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Contact tracing and the challenges of health equity in vulnerable Latino and Native American communities: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26174.
Health and Medicine Division
Copyright 2021 by the National Academy of Sciences. All rights reserved.