executive functions

‘Disease Detectives’ on Contact Tracing a Reckless President

Photo: Win McNamee/Getty Images

Despite several suspected “superspreader” events at the White House that seem to have turbocharged the coronavirus outbreak that infected President Trump and dozens of others, the West Wing has declined offers from the Centers for Disease Control and Prevention to “contact trace” to determine who else may be carrying the virus.

That news — and the basic lack of precautions taken by the administration — shocked and dismayed public-health experts who spoke to Intelligencer, including the former head of the CDC under President Obama and two veterans of the agency’s Epidemic Intelligence Service.

“As a general rule, the CDC doesn’t go anywhere it’s not invited,” said Dr. Tom Frieden, the former head of the CDC.

“If it were anywhere else, the local health department would be in charge, but because it’s Washington, D.C., and the White House, it’s really rather unprecedented,” Frieden said. “It’s really up to the White House Medical Unit and White House operations to either do [contact tracing] or delegate it.” On Tuesday, a White House spokesperson told ABC News the medical unit was contact tracing with someone detailed to the White House from CDC since March.

People now known to have been infected might have passed the virus on to others at five events at the least: a White House reception for Supreme Court nominee Amy Coney Barrett; an event the next day recognizing the families of deceased U.S. troops; a Trump campaign fundraiser at the president’s golf club in Bedminster, New Jersey; the first presidential debate in Cleveland; and a Trump campaign rally in Minnesota. And that’s not counting travel on Air Force One and Marine One.

“This could have been a teachable moment for the White House that testing is only part of a comprehensive safety plan,” Frieden said. “Instead, the White House over-relied on testing and let down their guard.”

Dr. Bob Wachter, the chair of the Department of Medicine at the University of California, San Francisco, said the events of the past few weeks should have been shocking, but, ultimately, the outbreak was inevitable.

“Once I saw him take off the mask or do the joyride with Secret Service agents or 100 other things that he’s done since March,” Wachter said, “this outbreak is anything but super-high on my list of things I’m shocked about.”

“This is what happens when you engage in unsafe behaviors for long enough. You can get away with it because the odds are in your favor, but at some point it catches up and clearly it’s caught up, not just to the president but to a whole swath of people,” Wachter added. “We’re getting up to numbers where it’s quite likely we’ll have some deaths. There’s a cinematic, Shakespearean part of all of this, that the superspreader event turns out to be the nomination event for a proposed Supreme Court justice at this stage of the campaign.”

In the absence of federal leadership, news outlets and amateur Twitter sleuths have attempted to trace the spread of the disease through Washington, much like re-creating a crime scene. But it’s not as easy as it sounds.

“Contact tracing really is a very complex art and skill. It requires a combination of great people skills, detective work, social work, crisis intervention, counseling skills,” said Frieden, who is now the president and chief executive of Resolve to Save Lives. “To become a good contact tracer may take years.”

Determining how a disease spreads and to whom is a core mission of the CDC’s Epidemic Intelligence Service, whose members are nicknamed “disease detectives.” While every infectious disease manifests differently, and the concept of “close contact” can vary depending on how a disease spreads, the discipline of contact tracing remains fairly consistent, whether it’s used on Ebola, Zika, tuberculosis, or COVID-19. And it starts with recall.

“The person that you’re trying to find out who they’ve had contact with have to be able to remember where they’ve been in the past ten to 14 days, and for a lot of people, that’s really very hard,” said Dr. Gavin Macgregor-Skinner, director of the Global Biorisk Advisory Council and a former Epidemic Intelligence Service officer. “The challenge we have — let’s say it’s salmonella or hepatitis or measles — if these people are really sick, they may not be in any condition to remember.”

For Macgregor-Skinner, who has worked on a range of infectious diseases, including COVID-19, the sleuthing in trying to piece together the puzzle of a person’s life can involve anything from assembling grocery, restaurant, and transit receipts to reviewing a patient’s call logs, texts, or emails, and more. He and his team have conducted home visits in countries around the world, made countless phone calls, and been sent away more often than not, particularly in the United States.

“The big challenge we have in the U.S. is if people don’t recognize the phone number, they refuse to answer or they think it’s spam. And when we go and actually visit the person in their house, they’re really reluctant to let people in,” Macgregor-Skinner said. “People are more open [in] other places. When I went to Samoa last year for the measles outbreak, you could just knock on any door and ask questions and they’d tell you their whole life story.”

If identifying known contacts is challenging enough, identifying unknown ones can be nearly impossible. Someone may remember that they ate lunch with a friend at a particular restaurant the prior Tuesday, and it’s easy enough to contact that friend. But what happens when they know they took the 8 a.m. Acela to New York on Friday and sat in the quiet car? Officials will then send out a community alert that anyone on that train at that time should contact a public-health official.

“It’s clear from the White House that they’re not a fan of contact tracing. I suspect, and this is just speculation, that’s because the president doesn’t want to do anything that increases the number of cases we have,” said Dr. Joel Selanikio, another former CDC Epidemic Intelligence Service officer, who is currently consulting with the District of Columbia’s Department of Health on COVID response. While a nondisclosure agreement prevents him from speaking directly about the work he’s doing with the D.C. government, Selanikio said, “Obviously, contact tracing does exactly that. If you have someone who thinks we can avoid the disease by not identifying cases, that goes against the scientific pursuit of the contact-tracing method.”

If the purpose of contact tracing is to identify and notify people who might have been exposed to a potentially deadly virus, it would serve little purpose for the attendees of the event at the Rose Garden, or in Bedminster, or at the presidential debate, or on Air Force One, according to UCSF’s Wachter.

“Often, contact tracing is about tracking people down who were exposed and didn’t know it,” Wachter said. “If you don’t know you might have been exposed at Bedminster or in the Rose Garden, you must be under a rock.”

While at this point, many of the people at those events no doubt know they have potentially been exposed, Frieden said it doesn’t absolve the White House of its responsibility.

“It’s like warning people that a hurricane is coming. We expect the government to do that,” Frieden said. “And you should expect the government to warn you if you’ve been exposed to an infectious disease that might kill you or kill your family member.”

‘Disease Detectives’ on Contact Tracing a Reckless President