Can Coronavirus Contact Tracing Survive Reopening?

A pointillism scene of various figures walking
Massachusetts created a pioneering program to track COVID-19 cases. Its challenges are multiplying as the state reopens.Illustration by Keith Negley

John Welch, a nurse anesthetist with the nonprofit Partners in Health, was working at a clinic on the rural central plateau of Haiti when, in August of 2014, he got a call asking if he could fly to Liberia. The charity had just agreed to help in the fight against Ebola, which had cropped up in Guinea that winter and was now spreading rapidly across West Africa. Welch, who specializes in pediatric surgeries, would go on to play a vital role in the American response to the coronavirus, but in 2014 he knew little about viral outbreaks and virtually nothing about Ebola. Within a week, however, he had flown to Atlanta, for a two-day crash course on the features of the disease, and then travelled to the Liberian capital of Monrovia.

It had been about three weeks since the World Health Organization had declared the outbreak a global emergency, and the press carried reports of bodies decaying on Monrovia’s streets. By the time Welch arrived, there were about a half-dozen Ebola-treatment units in or near the capital, most of them run by aid organizations. Those organizations, though, were just beginning to understand how complicated the epidemic would be, and how long it would take to control it.

A few months after arriving in Liberia, Welch was transferred to Port Loko, Sierra Leone, where P.I.H. had agreed to help manage a small hospital. Not long after he arrived, Welch, covered in protective gear, sat at the bedside of a young woman who was dying from complications of labor. Her doctors and nurses could not prove that she was not carrying Ebola, and no surgeon or midwife could be found who was willing to perform a C-section.

Port Loko was the hot zone. “Nothing was happening in that hospital besides Ebola,” Welch said. “The first month, all we did was try to clear some cases out of the hospital so that we could reëstablish essential services.” Tests were scarce, so patients were divided into positive cases, negative cases, suspected cases, and presumed cases, those who had not tested positive but were obviously symptomatic. Suspected cases were divided again, into “wet” patients, who had diarrhea and vomiting or were hemorrhaging blood from their orifices, and “dry” ones, who were not. Patients who had recovered were released from the hospital, but that meant persuading their families that they were no longer contagious. Often, when people developed fevers and went to the hospital, their possessions were set on fire or doused with chlorine, so the Port Loko hospital started sending patients home with cooking utensils, a cell phone and SIM card, and a little bit of cash.

By the end of 2014, the virus had been beaten back in the cities, although, at any time, there were a few hundred active cases, about half of them nestled in areas so remote that they could not even be reached by motorcycle. The outbreak’s last Ebola death was reported in April, 2016. “If you ask me how we beat Ebola in West Africa, there’s a three-second answer: contact tracing,” Welch said. He was referring to a simple public-health technique, developed during syphilis outbreaks in the nineteen-thirties, in which the infected are interviewed about the people they’ve come in contact with; those contacts are then asked to isolate themselves, in order to prevent the contagion from spreading further. At the time of the Ebola outbreak, Liberia’s public hospitals employed a total of fifty physicians—the country had few of the capabilities of a modern, Western-style health-care system. It relied instead on an army of amateur community-health workers, who could take on the work of contact tracing. Tolbert Nyenswah, who was Liberia’s deputy health minister at the time, told me, “Because we could not spare doctors or nurses, we hired social workers and schoolteachers as contact tracers—people who were respected in the community.” Welch recalled long meetings with village and tribal leaders, to identify trusted and influential people to hire as tracers. As soon as patients with Ebola symptoms arrived at Port Loko Hospital, they were interviewed about everyone they’d been in contact with since they first developed a fever. A contact tracer then went to the patient’s neighborhood to tell those contacts that they needed to isolate at home for twenty-one days. Every day for three weeks, the tracers would return, to insure that those people were still isolating, to check on their health, and to see if there was anything they needed.

Liberia, a nation of five million people, eventually employed as many as ten thousand tracers. Welch recalled that, after he had been in the region for eight months, “if you told me there would be an outbreak in a particular region, I could tell you which village. If you told me the village, I could tell you which house.” He told me this story one evening at the beginning of May, speaking by phone from his apartment in Boston’s South End, where he was helping direct a similar program, the Massachusetts COVID-19 Community Tracing Collaborative. The which house stage in Massachusetts, Welch said, felt far away. He told me, “I think we are at a similar point with COVID-19 to where we were with Ebola when I first arrived in Monrovia.”

The Community Tracing Collaborative, or C.T.C., which was publicly announced at the beginning of April, was one of the first and largest contact-tracing programs to be launched in response to COVID-19, and it has provided an early model for similar programs developed by cities and states across the country. But the C.T.C. was even more notable because it had been developed by Partners in Health, an organization whose fame far exceeds its hundred-and-forty-million-dollar budget. The nonprofit’s founders, who established the organization in the late nineteen-eighties, are among the most famous figures in public health: they include Paul Farmer, who is renowned for his humanitarian work in Haiti and is the author and subject of best-selling books; Ophelia Dahl, who ran the organization for over a decade; and Jim Yong Kim, who, from 2012 to 2019, was the president of the World Bank. P.I.H.’s mission has long been to build durable medical systems in the poorest parts of the poorest countries on earth, by training local community-health workers and allowing them to mold programs to local needs. Much of P.I.H.’s work has been in the least developed countries. And so the decision to have the group design and administer the COVID-19 response in a city filled with world-class hospitals also suggested that, in a crisis, the American health-care system needed tools and resources that it didn’t already have.

Massachusetts’s first confirmed COVID-19 cases appeared in February—a cluster connected to a corporate meeting held by the pharmaceutical company Biogen, at the Boston Marriott Long Wharf. On March 3rd, the state’s first case of community transmission emerged, in the Berkshires, and a week later the governor, Charlie Baker, declared a state of emergency. At the time, the state had only ninety-two confirmed cases, three-quarters of which could be traced to the Biogen conference, but that low figure was due to a shortage of tests: it was clear that the virus had spread much farther. During the first week of April, the total number of deaths in the nation more than doubled, from forty-seven hundred to more than twelve thousand. The number of cases—and hospitalizations, and deaths—was rising fast enough that Boston’s biggest hospitals were drawing up protocols that would help them decide who would be allocated a ventilator if the intensive-care units were overwhelmed.

Paul Farmer watched these events with other global-health emergencies at the front of his mind. When epidemics strike the poorest countries on earth, he told me, public-health professionals often succumb to what he calls “clinical nihilism”—the conviction that the number of cases is too overwhelming for doctors to treat, and that the only realistic approach is to contain the spread. As COVID-19 cases began to proliferate throughout the United States, Farmer said, “a lot of us predicted that there would be containment nihilism instead”—that governments would give up on even trying to control the disease and plan for herd immunity instead. Farmer explained, “In its worst form, it’s basically just, ‘Let the immune system take care of it.’ ” But by late March lockdowns had been imposed in thirty states, and it was obvious that most political leaders were willing to make sacrifices to prevent their constituents from getting sick. This was “a pleasant surprise,” Farmer said. But the lockdowns were always intended to be temporary, and there was not yet any national plan for what would take their place.

Meanwhile, Jim Yong Kim was speaking with public-health leaders who were battling the virus in Asia. The lockdown in Wuhan, China, had at that point dramatically reduced transmission but hadn’t ended the spread. “It’s almost as if there are two different rates of transmission—one outside of households and one within households,” Kim told me. “In Wuhan, the lockdowns were effective on transmission outside of households,” he said. But plenty of transmissions were still happening within homes. “So lockdown was not going to be enough.” A better strategy, he believed, and one that could help monitor outbreaks even once restrictions were lifted, was to apply the basic contact-tracing formula: test for the virus, trace anyone in close contact with an infected person, and have them enter isolation. “The U.S. is different from China—it can’t do anything on a mandatory basis,” Kim said. “But the best way to stop families from infecting one another is that, once someone becomes positive, you have to separate people.”

What Kim envisioned was a radical, emergency expansion of the American public-health infrastructure—a rapid increase in testing capacity, hundreds of new contact tracers, social workers to help insure compliance, and isolation hotels for the sick who could not safely isolate from the people with whom they lived. Kim has known Baker, a moderate Republican, for about fifteen years, and, during the last weekend of March, he called the governor with a proposal. Drawing on staff who had helped contain outbreaks in developing countries across the globe, P.I.H. would design and implement a contact-tracing program for Massachusetts. It would need the state to supply funding to hire a thousand tracers. The next day, Farmer was at the State House, waiting to present a more detailed proposal to the governor. Kim, who has a pragmatic disposition, and Farmer, who has a more idealistic one, had anticipated that the main argument against their program would be that the outbreak in Massachusetts was simply too advanced for contact tracing to do much good. But, Farmer recalled, “Baker walked right in and said, ‘I’m really so fucking sick of people saying it’s too late.’ And we thought, All right, cross that one off the list.” That week, the governor announced that he was dedicating forty-four million dollars to a new contact-tracing program, to be run by P.I.H.

P.I.H. normally sends idealistic young physicians and nurses from Boston to destinations overseas; now it recalled them from Rwanda, Lesotho, and Haiti to lead the Massachusetts program. Emily Wroe, who had just wrapped up a stint as P.I.H.’s chief medical officer in Malawi, came back to the U.S. and signed on to oversee the program’s design and implementation. She divided the project into three job categories. Case investigators would quickly call people who had tested positive for the virus and interview them extensively about their contacts, beginning forty-eight hours before they first noticed symptoms. Contact tracers, the largest group, would call each of those contacts, ask them to isolate at home for fourteen days, and then follow up frequently, to make sure that they were doing so and to check for any symptoms. The third group, care-resource coördinators, were effectively social workers, appointed to help people solve problems—how to get food, find a place to stay, or manage addictions—that might prevent them from being able to isolate themselves. The idea was that this workforce would accompany each person through their illness or isolation—that, instead of an authoritarian hand requiring people to stay at home, the state would extend a helping one.

In a certain sense, something very simple was happening: in a public-health emergency, a rich state was hiring more public-health workers. But to the P.I.H. staffers the stakes seemed higher. Wroe said, “I think there’s a story in what we’re doing, where it’s about the community banding together to take care of everybody. Where there are humans on the phone calling to check on you and to help you think through, if there are people in your household that depend on you, how do you get tested, how do you isolate, how do you keep them safe?” Having once brought Boston-style medicine to Haiti, now P.I.H. was trying to bring some elements of Haiti-style medicine to Boston. “Reverse innovation,” Farmer called it, with some pleasure in his voice. Of course, they still had to prove that this approach could work—that all that gentle coaxing and assistance could persuade people to isolate, and stamp out the disease.

Much of the public discussion about solutions to the pandemic has focussed on the efforts of experts—to develop a more precise test, more effective treatments, and, eventually, a vaccine. Meanwhile, as every state in the country has begun, more cautiously or less, to ease restrictions, forty-four of them have developed plans like Massachusetts’s—to hire enough contact tracers for communities to monitor outbreaks themselves. When it comes to contact tracing, however, the states are largely on their own. Although Anthony Fauci, the President’s leading public-health adviser on the crisis, said at a press conference in mid-April that “the real proof of the pudding” of reopening would be how quickly new outbreaks could be traced and isolated, the federal government has offered little guidance on how states should do that. A Johns Hopkins report estimated that Congress would need to appropriate 3.6 billion dollars in emergency funding to pay for contact tracing nationwide; the CARES Act, passed in early March, allocated about a sixth of that amount to contact tracing. The Centers for Disease Control and Prevention advised that contact tracing was warranted for anyone who had been within six feet of an infected person for ten minutes, but offered no guidance on program design. How many people each state would need, whether the hires needed to be medical professionals, what outcomes they ought to measure, and what standards would indicate success—all of this was left up to the states.

Within days of Baker’s announcement, Farmer and Kim were receiving calls from governors and state health directors around the country, who were trying to set up their own programs. Farmer chose to see this in an optimistic light. “Some people seem to be spurred by the gravity of the economic collapse, others by fear—the usual menu of human motivation,” he said. “But if the governor of Illinois and the governor of Ohio call on the same day to ask about contact tracing, I mean, we care about their motivation, but they aren’t coming to us because we’re political.” As part of the P.I.H. model in Massachusetts, which has become the basis for many other states’ programs, the tracers are given scripts, but the essential part of their job is to persuade the contacts to isolate at home. Really, the tool is just talk. On the spectrum of possible policy responses, most states have chosen one of the least authoritarian imaginable to try to contain the spread. It is a program of voluminous coaxing.

In early April, Baker, alongside representatives from Partners in Health, held a press conference to announce the creation of the Community Tracing Collaborative. The same week, P.I.H. launched a job-application page for case investigators, contact tracers, and care-resource coördinators, with full-time applicants preferred. Since March, more than nine hundred thousand people in Massachusetts have filed for unemployment; within three weeks of the C.T.C.’s launch, twenty-two thousand people had applied to work for the contact-tracing program. This created a somewhat ludicrous situation. The intent of the project was to create a workforce of working-class Massachusettsans who knew their own communities and how to heal them, but the volume of applications meant that it was harder to get hired as a contact tracer, at about thirty dollars an hour, than it was to gain undergraduate admission to Harvard.

Many of the new hires were almost comically overqualified. I spoke with one case investigator in Quincy, David S. Novak, who turned out not only to have spent more than a decade at the C.D.C. but also to have written a manual, which the agency still uses, on how to track sexually transmitted diseases on hookup apps. Krysta Cass, a supervisor on the Boston team, is not only a surgical physician’s assistant but also a Yale business student and a West Point graduate, who served as an Army officer on two tours in Afghanistan. I learned about a care-resource coördinator who was placing calls from the Roxbury neighborhood where he had grown up in public housing, after his parents brought him to the U.S. from the Dominican Republic as a toddler. These details about Oscar Baez were all true, but he also turned out to be an Amherst graduate and foreign-service officer who speaks nine languages, and who was taking a State Department course to brush up on his Arabic.

The risk was that the C.T.C. could be seen as a group of idealistic but scarcely trained outsiders. This mattered, because by mid-April it was clear that the state’s cases were densely clustered in a few working-class neighborhoods on Boston’s northeastern border: East Boston, inside the city line, and Chelsea and Revere, just outside of it. In Chelsea, COVID-19 was so widespread that, when researchers took blood samples from two hundred people walking at random near city hall, they found that thirty per cent of them had antibodies to the virus. Chelsea’s population is two-thirds Latino, and many people are undocumented and out of work. “There’s no underground economy left—no one’s hiring people for day labor, or to come and clean their homes and bathrooms,” Chelsea’s city manager, Tom Ambrosino, told me. People were sick, but they were also reluctant to give up the work they had, so the virus continued to spread.

“When it comes to the ability of people to isolate, that’s very difficult here,” Cate Fox-Lent, a recent graduate of Harvard’s Kennedy School of Government, who has been directing Chelsea’s public-health response, told me. “We definitely have situations where there’s a three-bedroom apartment that has a couple in one bedroom, a single man in the second bedroom, and a family of four in the third bedroom.” Residents of Chelsea had significant needs—they often needed medical attention or food; they needed to trust a caller enough to report a contact who might be undocumented. Fox-Lent said that, in her experience, contact-tracing calls from strangers, no matter how attentive and frequent, were missing too much. “We’re just not getting in touch with everyone—people are afraid,” she said. “I just don’t know that it’s doing anything to manage the situation. It’s just trying to keep tabs on it.”

Just before 8 A.M. on a Friday in early May, Eliton Comin sat on a soft couch in his living room, in Tewksbury, and assembled his one-man call center: phone, laptop, earbuds. He pulled up a list of a half-dozen people who had recently tested positive for COVID-19 in a few towns near him—Chelsea, Revere, and Brockton—and who, like him, primarily spoke Portuguese. There was a second list, of people who had not tested positive but who had been in close contact with someone who had been contagious, and a third list, of people Comin had spoken to earlier in the week, and who required a shorter follow-up. Calling from his couch, Comin found that he had just one tool to rely on: his voice, which he had to calibrate to be approachable and authoritative at once. He wanted to be sure not to spook anyone on his list, or to seem to intrude. He also avoided the word “track,” because it could have scary implications for an immigrant, and spoke Portuguese rather than English, because it suggested he was not the state, but something like a friend.

Comin’s first contact that morning was an elderly man, who spoke such formal, old-world Portuguese that he struggled to understand Comin, who had grown up in the southern Brazilian state of Santa Catarina. Comin slowed down and repeated himself: he was with Massachusetts’s coronavirus-tracing project, the call was anonymous, and he wanted to see how the man was doing. The conversation became easier. The man had tested positive for COVID-19 at a hospital not long before, but he had paid close attention to the directions he received, and he was staying isolated at home, where he lived alone. A daughter, he said, would come by and drop off food; he had everything he needed. Comin asked the man to think back to forty-eight hours before he’d first noticed any symptoms, and talked him through everyone he had come into close contact with. There was just his daughter, who had tested negative, and one friend, who had tested positive. Eventually, the conversation slowed down. “To tell you the truth, I’m lonely,” the man said. Usually, he would walk to the fence in his yard and speak with his neighbors, but they, too, were old and vulnerable. He told Comin that he wanted to be sure that he didn’t make his friends sick, and so now he just watched them from his window.

Next, Comin reached a husband and wife, both of whom had tested positive for COVID-19, and who lived in a one-bedroom apartment with their twelve-year-old son. They’d come up with a solution to avoid exposing their child to the virus—he would stay with a neighbor. At first, Comin approved, but the more they talked about it the riskier it seemed. If the boy had already caught it from his parents, he could easily infect the neighbor. Then it turned out that the neighbor was dropping by regularly to check on them. The situation seemed iffy. If the son were older, he might have voluntarily moved to an isolation hotel in Revere, but that wasn’t a realistic option for a kid. Eventually, after confirming that the neighbor had tested negative and talking to a supervisor, Comin decided that the neighbor’s apartment was the least problematic option. Even so, he made a note to check on the family every day.

Comin, who is thirty-seven and thickly built, with a bushy goatee, had been laid off from his job as a chef for a catering company shortly after Massachusetts went into lockdown. He felt fortunate that he had previously become a citizen and qualified for unemployment insurance—one of his friends from the catering company was scrambling for work, applying to every Dunkin’ Donuts franchise he could find. Comin’s girlfriend is a nurse anesthetist at Boston Children’s Hospital with John Welch, the nurse anesthetist who is helping run the C.T.C. program, and through him Comin learned that Portuguese-speaking tracers were needed. The marginal position of the Brazilian immigrants in Massachusetts represented a potential hole in the monitoring system that the C.T.C. was trying to build. Welch had come up with a characteristically P.I.H. solution, which was to fill that hole not with a protocol but with a person, Comin, whose life experience meant he might be trusted by the people he interviewed. Comin had arrived in the United States at the age of nineteen, a punk-rock enthusiast who came to Massachusetts because his aunt lived there; after his tourist visa expired, he was grateful for the older immigrants who had explained the rules of a new country to him—how, for example, when you stopped at a stop sign, you really had to stop, in order to avoid being arrested. To Comin, teaching people how to isolate at home during a pandemic, when they might not be here legally or have health insurance, was something like explaining the full and complete stop.

When Comin had started the job, his first calls slightly unsettled him. Sometimes, he could tell that his contacts weren’t being forthcoming with him. Several people, having figured out what he was calling about, asked him for cash, which disappointed him. Over time, he had grown more familiar with the kinds of issues his interviewees were struggling with, and the type of persuasion required. After calling the parents of the twelve-year-old, Comin spoke with two cousins he’d been tracking all week, both of whom had tested positive. (One had driven the other to the hospital to be tested, and in so doing had probably caught the virus himself.) One cousin worked in construction, the other in a sub shop, and when Comin reached the food worker he found that the man was growing anxious. “When can I go back to work?” he asked. The man insisted that he had no symptoms, and said that the sub shop was planning to reopen and he didn’t want to lose his job. Comin tried to parry. “The worst thing would be if you go back too early,” he said—he might get customers sick, and that might make his boss angry. That didn’t sway the man. Comin remembered an Internet meme he’d seen, in which a man halfway down a parachute jump decides to close his chute, insisting it has done its job perfectly. “That would be crazy, right?” Comin said. The man agreed, but Comin wasn’t sure that he’d convinced him.

Throughout the spring, the Massachusetts contact-tracing program got faster. It took between three and four days for the C.T.C. to learn of a positive test, but after investigators had that information they were able to reach seventy per cent of cases, and contact tracers were then able to speak to seventy-four per cent of those cases’ contacts. This still meant that nearly half of potential contacts never spoke with anyone working for the tracing program. Crystal Watson, a health-policy expert at Johns Hopkins, who co-authored a report in April on contact tracing, told me that these numbers were better than she had expected. “Even if you’re only getting half of all contacts, that’s a lot better than we would have been doing without the program,” she said.

But, until June, Massachusetts remained under lockdown—a temporary and highly artificial situation in which each case had, on average, about two contacts. That changed with the George Floyd protests, when crowds returned to the state’s public spaces. Thousands of people gathered outside the gold-domed State House in Boston, and hundreds more came together in Cambridge, Worcester, and Brockton, two towns over from Revere. Wroe, the C.T.C.’s director of implementation and design, had her eye on the protests but said that they were simply too difficult to trace. When contagious people told investigators that they had travelled on a bus, or visited a nursing home, the C.T.C.’s protocol was to alert the local Board of Health and move on. Wroe also believed that Massachusettsans did not want a program that would find ways to track their public movements. She said, “I don’t think there’s much epidemiological advantage in chasing people down in public places, versus the very real risk of losing trust.”

New York State, the epicenter of the American COVID-19 outbreak and the site of some of the largest protests in recent weeks, launched its New York City program in early June, with an initial group of seventeen hundred tracers. The program, run by New York State’s Department of Health, working with Bloomberg Philanthropies and Johns Hopkins, eventually plans to hire a staff of up to seventeen thousand. As New York State reopens, its program also seems unlikely to trace contacts through protests and other crowds—officials have said that they won’t trace potential contacts on the subways. Tom Frieden, who led the C.D.C. during the Obama Administration and is consulting on New York’s contact-tracing project, told me, “Big picture, the U.S. is just way behind.” Without widespread contact tracing, the U.S. doesn’t know how many cases do not have an identifiable source of transmission, but it’s almost certainly in the tens of thousands. “We have this enormous outbreak, we’re working really hard on it, there’s a lot you can do to control it—but, look at this, we’ve got unlinked spreading in the community, and that means it could explode.” Frieden said. The American response, in his view, was characterized by “this kind of lack of seeing the essence of what’s important.”

Many states have also launched contact-tracing programs without what P.I.H. considers one of the most vital components—the care-resource coördinators who help solve the problems, like a need for food or medicine, that keep people from isolating. Mike Reid, an infectious-disease doctor at the University of California, San Francisco, who is helping design the city’s contact-tracing program, said that there was an active debate over whether to include care-resource coördinators. Reid believes that the role is “absolutely critical,” he told me, but because of funding concerns it was likely to be cut from the San Francisco program. “We’ve had plenty of states get on the phone with us, and you get to the care-resource-coördination part, and you can just see their eyes glaze over,” one P.I.H. staffer told me. “Like, ‘Wait, these aren’t contact tracers? Why do we have to pay for this again?’ ”

The answer, at least for the P.I.H. staffers, was that, without helping people to isolate, you would never persuade them to do so. The full contact-tracing process is “the bulwark of how we will reopen,” as George Rutherford, an epidemiologist at U.C.S.F., who is also working on California’s statewide program, put it. But contact tracing can’t easily solve the problems that are typical in the places where outbreaks tend to occur—prisons, nursing homes, and protests—or the policies that help determine who stays home and who doesn’t. What it has to offer, to try to insulate communities from the virus, is the attention of individual people: tracers, investigators, resource coördinators. The more of them you have, the better the odds.

Americans facing this pandemic have a luxury that was not available to those who experienced the Spanish flu a century ago, or to those who faced Ebola in West Africa in 2014: most of us have access to a constantly evolving bird’s-eye view. Curves, graphs, and maps are updated daily. The big picture is almost instantly legible. In early June, the news was still reporting each turn in the pandemic—across the country, there were slow declines in the major epicenters, and a steady, intriguing resistance to the virus in Florida. In Boston, more than half of deaths turned out to be connected to nursing homes. But I found that the contact tracers in Massachusetts were not so focussed on those patterns. Emily Wroe told me that the critical element the American system seemed to lack, which made tracing especially hard, was the social safety net—the C.T.C. was forever trying to stitch together its holes. The tracers were preoccupied with the daily work of contact and isolation and need. Detective work had become medical work, which in turn became social work. It was the way of epidemics.

Oscar Baez, the foreign-service officer, has been working as a care-resource coördinator, the position within the C.T.C. that does the most socially complicated work. His language skills mean that he often calls immigrant homes where people speak Spanish, Arabic, Haitian Creole, or Cape Verdean Portuguese and Creole. Baez said that his clients have “tested positive because their jobs required them to be caregivers—to work in hospitals, to be nursing assistants. We required them to continue to expose themselves, and now we’re requiring them, in terms of solidarity, to flatten the curve, to stay home. But they continue to put themselves at risk, because they can’t get food. They don’t have anybody to deliver the groceries. That’s where we step in.” Baez has a long list of agencies supplying various services, and volunteers willing to run errands for people who can’t. Much of his day is spent finding someone to pick up a particular bag of groceries from a particular food pantry, or a nebulizer from a pharmacy, and drop it off on a doorstep. Baez said he thought that the many needs and fears of the people he called were evidence of a “broken immigration system.” He did not go further—he was still a member of the foreign service. “You’re not going to flatten the curve if they can only live in the shadow,” Baez told me.

The social safety net for immigrants in Boston can seem so porous that it might as well be all holes. Baez has been trying to make it airtight. “What people really want is to feel secure,” he told me when I called him one evening in May, just after his shift had ended. He began to talk through the cases he’d worked that day. All of the adults in a household had tested positive for the coronavirus, and they wanted to know how they could safely share one and a half bathrooms without infecting the children, or re-infecting one another. Another call came from a pregnant woman—who, Baez said, was “the most nervous person I spoke with today.” She and her husband, who both work at McDonald’s, had tested positive and had to stay home for two weeks. She was worried about eviction, and money for the baby, if they lost their jobs. A call came from a woman who worked as a nursing assistant at an assisted-living facility, who had just tested positive, along with many of her colleagues. “Everyone on my floor got it,” she told Baez. She was isolating at home and needed a nebulizer for her asthma, but didn’t have a hundred dollars to pay for it, so she had to figure out a way to purchase the device and then find a volunteer to pick it up at the pharmacy and drop it off on her doorstep. Baez said that this work reminded him of the challenges he has had trying to respond to emergencies overseas: “If there was equity, period, there wouldn’t be a need for us to fill these gaps.”

A thousand tracers, in the middle of a pandemic, gets you somewhere, but maybe only partway. In the evenings, when Baez walks around his parents’ neighborhood, he often passes Boston Medical Center, which runs a large opioid-addiction program, and where he can see clusters of addicts on the street corners. They’ve still been getting their methadone, but their presence reminds Baez of all the vectors for transmission that might still be beyond his compass, and the gaps in care he can’t cover. Baez told me, “Obviously, we can’t promise the world.”


A Guide to the Coronavirus