One August day in 2017, a 31-year-old man with a cough boarded a crowded minibus in Madagascar's capital, Antananarivo.
The man was dead before he could reach his destination.
That touched off the most lethal outbreak of pneumonic plague in decades. By the end of November, more than 2,400 people had been infected and 209 had died.
Basketball teams from around the Indian Ocean region were in Madagascar at the time for a championship tournament. A coach from the Seychelles died and a South African player fell ill. The risk of an international outbreak loomed.
To stamp it out, health officials needed to break the chains of transmission: find the people who had come into contact with each infected individual and prevent them from spreading the disease to anyone else.
It's known as contact tracing. It's the same task that experts now say the United States must dramatically increase as COVID-19 lockdowns loosen. COVID-19 is the disease caused by the coronavirus.
COVID-19 infections will inevitably increase in the coming weeks, they say, and a work force must be standing by to stop new patients from rekindling a widespread outbreak. Tiny Madagascar’s experience could provide the U.S. and other countries with valuable lessons and insights.
Eyes and ears
While health officials say the United States will need to hire at least 100,000 contact tracers, Madagascar tapped into a network of community health volunteers who were ready to step in when the outbreak hit.
Those volunteers go door to door in communities across the country as health educators. They make sure pregnant women get pre-natal care and children are vaccinated. They treat common ailments, such as malaria, diarrhea and pneumonia.
"They're the eyes and ears of the health system," said John Yanulis, who directed the program for the nonprofit Management Sciences for Health. "They are trusted members of their community."
So when the volunteers were called upon to become pneumonic plague contact tracers, the community already knew them and listened to them. People were willing to share information about who was at risk.
Pneumonic plague is 100% fatal within days if left untreated. The community health volunteers delivered antibiotics that would prevent infection.
Occasionally, though, people would not take them.
"Fear, I think, was one of the biggest factors," Yanulis said. People "did not know how to deal with that news" that they might have been exposed to a lethal disease.
Health volunteers would "go up the chain" to deal with refusals, he added. They'd call in the head of the local health center, the village watch committee, and even the mayor to "basically talk it through" and "ultimately convince the person that it's not just for your good, it's also for the good of the community."
Then the volunteer would go back every day during the one-week course of antibiotics to make sure the person took them.
The contact tracers were part of a coordinated effort from local, state and national officials, plus international partners, including the World Health Organization.
"In 2½ months, we had a real public health success," Yanulis said. New cases dropped sharply in October. On December 4, the WHO declared the outbreak contained.
The same volunteers are "at the ready" to deal with COVID-19, he added. "In some cases they are already being oriented and trained."
While they are unpaid in Madagascar, community health workers are on government payrolls in Kenya, Ethiopia, Malawi and other countries in Africa and elsewhere, Yanulis said.
In the United States, states, cities and counties are preparing to hire thousands of people to do the same kind of labor intensive, high-touch work that helped Madagascar contain its outbreak.
They don't need much education, Yanulis said. "It's really about being someone who is comfortable going into the community."
Before COVID-19, much of the contact tracing U.S. health departments did was for sexually transmitted infections, which carry more of a stigma than the coronavirus infection.
The process is basically the same, said Tim Heymans, a disease intervention specialist with the Minnesota Department of Health. When he calls a contact, the first question he asks is whether the person can speak privately. "When you show them that you're trying to protect their privacy, I think that builds trust."
When he delivers the news, "they may be shocked at first or are upset or defensive." Some get angry and don't cooperate, but, he said, "most of the time within moments, they're giving signs that they're glad that we called and are happy for the advice we're giving them on where they can go to get help with this."
For the most difficult cases, Heymans said, "we try to appeal to the person's sense of the greater good and protecting people around them."
'Complicated and messy'
COVID-19 contacts need to isolate themselves for 14 days, which can be a lot to ask.
A person might be taking care of elderly relatives and young children. Staying at home risks spreading the infection to vulnerable family members, said Adriane Casalotti, governmental and public affairs chief at the National Association of County and City Health Officials.
But "if they leave," she asked, "who's going to help pick up the slack?"
Health departments may need to support people in quarantine with housing, food, medicine and even financial help.
"People's lives are complicated and messy," she said. "So the public health response ends up being complicated and messy."
With states looking to hire thousands of contact tracers quickly, Johns Hopkins University has developed a five-hour online training course covering the basics of the disease, contact tracing and how it works, and some of the privacy and ethical issues involved.
It also covers how to build rapport, "because ultimately, this is a program about connecting with people and helping support them to stop the spread," said course instructor Emily Gurley at Johns Hopkins.
Entry-level contact tracing jobs pay in the mid-$30,000 range, according to NACCHO's Casalotti. The organization said Congress needs to provide $7.6 billion for health departments to hire at least 100,000 of them, plus another 10,000 supervisors and 1,600 epidemiologists.
With tens of millions of people out of work, there's no shortage of applicants. Massachusetts had 40,000 applicants for 1,000 positions, according to USA Today.
Being out of work is just part of the surge of interest, Casalotti said. "I think a lot of people are stuck at home and they're watching this all happen outside their windows and they want to help."
When the COVID-19 pandemic hit, Casalotti noted, health departments had not recovered from steep budget and staffing cuts made in the wake of the 2008 financial crisis.
Given the economic devastation the pandemic is causing to state and local budgets, she is worried that history will repeat itself.
"We're actually really concerned, if this is anything like the 2008 recession, that local departments on the front lines of this response ... will end up being in worse financial shape after coronavirus than they were before," she said.