Contact Tracing Via Old Shoe-Leather Epidemiology While Spurning the Techno-Fix Fairy: How Hong Kong Quells COVID-19 Without Killing Civil Liberties

By Jerri-Lynn Scofield, who has worked as a securities lawyer and a derivatives trader. She is currently writing a book about textile artisans.

Many countries are trying to quell their COVID-19 outbreaks by submitting to the tender ministrations of the technofix fairy, willingly sacrificing civil liberties to untested tracking apps.

Now, I’m not going to deny that technology – including some form of contact tracing via mobile ‘phones – is part of future COVID-19 management. But the necessity of over-reliance on such tracking is far less clear.

And we just have to look to the case of Hong Kong, which has so far registered only four COVID-19 deaths, to see that health authorities can effectively track and trace via old shoe-leather epidemiology and not rely on any app at all.

Naomi Klein penned a chilling account in The Intercept recently, describing the future that New York state’s politicos, led by NY governor Andrew Cuomo, and Silicon Valley, spearheaded by Google CEO Eric Schmidt, have teed up. I encourage you to read  this article if you have not done so already (Screen New Deal). Following Rahm Emmanuel’s advice – “You never let  a serious  crisis go to waste” – and realizing most people are so petrified by the prospect of catching COVID-19, those who seek to construct a high-tech dystopia know the mass of people are all too willing to capitulate:

It has taken some time to gel, but something resembling a coherent Pandemic Shock Doctrine is beginning to emerge. Call it the “Screen New Deal.” Far more high-tech than anything we have seen during previous disasters, the future that is being rushed into being as the bodies still pile up treats our past weeks of physical isolation not as a painful necessity to save lives, but as a living laboratory for a permanent — and highly profitable — no-touch future.

It’s a future in which our homes are never again exclusively personal spaces but are also, via high-speed digital connectivity, our schools, our doctor’s offices, our gyms, and, if determined by the state, our jails. Of course, for many of us, those same homes were already turning into our never-off workplaces and our primary entertainment venues before the pandemic, and surveillance incarceration “in the community” was already booming. But in the future under hasty construction, all of these trends are poised for a warp-speed acceleration.

This is a future in which, for the privileged, almost everything is home delivered, either virtually via streaming and cloud technology, or physically via driverless vehicle or drone, then screen “shared” on a mediated platform. It’s a future that employs far fewer teachers, doctors, and drivers. It accepts no cash or credit cards (under guise of virus control) and has skeletal mass transit and far less live art. It’s a future that claims to be run on “artificial intelligence” but is actually held together by tens of millions of anonymous workers tucked away in warehouses, data centers, content moderation mills, electronic sweatshops, lithium mines, industrial farms, meat-processing plants, and prisons, where they are left unprotected from disease and hyperexploitation. It’s a future in which our every move, our every word, our every relationship is trackable, traceable, and data-mineable by unprecedented collaborations between government and tech giants.

The Case of Hong Kong

I checked in again this week with my old friend, Dr. Sarah Borwein, who has practiced medicine for the past fifteen years in Hong Kong. Sarah has on two other occasions shared with Naked Capitalism readers what this city of 7.5 million residents has done to stem the spread of COVID-19, while limiting cases to just over 1000, and deaths to four. (See Tale of Two Cities Redux: HK to Ease its COVID-19 Restrictions, While NYC Situation Remains Dire and A Tale of Two Cities: How Hong Kong Has Controlled its Coronavirus Outbreak, While New York City Scrambles).

She sent me an excellent article from The Atlantic: How Hong Kong Did It. One thing I’ve found troubling in discussing the U.S. and especially the NYC situation is that people are all too willing to blame the failed COVID-19 response on Donald Trump – as if he alone is responsible for the debacle. What the Atlantic piece makes clear is that Carrie Lam, Hong Kong’s hapless chief executive, also bungled Hong Kong’s initial response. Badly. From The Atlantic:

Lam fumbled the response to the pandemic as well, reacting with ineptitude, especially at first. Hong Kong’s first coronavirus case was reported when she was having dim sum with world leaders in Davos, Switzerland, and there was an outcry over the fact that she did not quickly return. She dragged her feet in closing the city’s borders, and never fully closed down the land border with China. The hospitals suffered from shortages of personal protective equipment. Lam wavered on masks, and even ordered civil servants not to wear them. There were shortages of crucial supplies and empty shelves in stores, as well as lines for many essentials. In early February, the financial outlet Bloomberg ran an opinion piece that compared Hong Kong to a “failed state”—a striking assessment for a global financial center and transportation hub usually known for its efficiency and well-functioning institutions.

And yet there is no unchecked, devastating COVID-19 epidemic in Hong Kong. The city beat back the original wave, and also beat back a second resurgence due to imported cases. But unlike in Taiwan or South Korea, this success can’t be attributed to an executive that acted early and with good governance backed by the people.

So, why is Hong Kong showing such success in COVID-19 management? For starters, their public health authorities knew what to do to control a pandemic, having learned painful lessons from two previous outbreaks Hong Kong wasn’t so successful in managing: the 1968 influenza epidemic, later dubbed “the Hong Kong ‘flu”; and the 2003 SARS episode.

Yet equally if not more important was the role played by Hong Kong’s people themselves in stemming the spread of COVID-19. Over to The Atlantic again:

The secret sauce of Hong Kong’s response was its people and, crucially, the movement that engulfed the city in 2019. Seared with the memory of SARS, and already mobilized for the past year against their unpopular government, the city’s citizens acted swiftly, collectively, and efficiently, in effect saving themselves. The organizational capacity and the civic infrastructure built by the protest movement played a central role in Hong Kong’s grassroots response.

In a way that eerily foreshadows a similar debate in the US, but with one crucial difference, Hong Kong residents took the lead in promoting the use of masks – despite initially contrary advice from the World Health Organization and lack of support from the government and Lam (who had banned mask wearing during the recent period of political unrest):

In response to the crisis, Hong Kongers spontaneously adopted near-universal masking on their own, defying the government’s ban on masks. When Lam oscillated between not wearing a mask in public and wearing one but incorrectly, they blasted her online and mocked her incorrect mask wearing. In response to the mask shortage, the foot soldiers of the protest movement set up mask brigades—acquiring and distributing masks, especially to the poor and elderly, who may not be able to spend hours in lines. An “army of volunteers” also spread among the intensely crowded and often decrepit tenement buildings to install and keep filled hand-sanitizer dispensers. During the protest movement, I had become accustomed to seeing shared digital maps that kept track of police blockades and clashes; now digital maps kept track of outbreaks and hand-sanitizer distribution.

A key takeway from The Atlantic:

There’s a lesson here, as the United States deals with staggering levels of incompetence at the federal level. Stories have been written by doctors in major hospitals in the U.S. about how they tried to source masks in the black market and disguised PPE shipments in food trucks to avoid their seizure by the federal government. As Taiwan and South Korea show, timely response by a competent government can make the difference between surrendering to a major outbreak and returning to a well-functioning, open society without lockdowns or deaths. But Hong Kong also teaches that people aren’t helpless, even when their government isn’t helpful.

Test and Trace

Yet it’s not due to its people alone that Hong Kong has dodged a severe COVID-19 outbreak. The Atlantic article affirms that Hong Kong has proactive, effective medical expertise, which was brought to bear in framing its COVID-19 strategy:

Thanks partly to their long history of fighting epidemics, Hong Kong also has some of the world’s most prominent experts in infectious diseases. They were cautious about picking open fights with their government or with China, but were clear in prioritizing public health. Defying China’s pronouncements about lack of evidence for human-to-human transmission and ignoring the WHO, which relayed those pronouncements to the world, the experts stated from very early on that they suspected the disease was transmitted among peopleand acted accordingly in their recommended safeguards. Despite the Hong Kong government’s continuing ban on face masks, Hong Kong’s health authorities openly credited the near-universal mask wearing among the people for avoiding a surge in cases.

Something the article doesn’t emphasize but should is the importance of painstaking test and trace measures to plot and thwart the course of COVID-19 spread.

Sarah described what has been undertaken as “old shoe-leather epidemiology.”  No app. No technofix fairy. Just hard work.

I asked her to explain what test and trace means to Hong Kong health authorities.

Sarah Borwein: So we had 21 days with no local cases and then a case was detected 2 days ago, and now her grand-daughter and husband have tested positive. What they are doing reflects their strategy:

They did extensive interviews with the index case (the 66 year old grandmother) and retraced everywhere she’d been in the 2-3 days prior to getting sick – every market stall etc. She looks after her 5 year old grand-daughter who is also positive – so they have also traced all her contacts. She attends a tutorial school, so the teachers and other kids.

And now they are conducting testing for 860 families who live in her housing block or the grand-daughter’s, or work in the market or work in or attend the tutorial center. At least 5000 people from 1 case!

They actually do something similar whenever we have a local case of dengue fever (not endemic here) – so they do have practice.

Jerri-Lynn Scofield: So, that’s what test and trace means!  And not via an app.

Sarah Borwein: No, not via an App

Although there are websites where you can see the locations of all the positive cases, and any flights etc (including seat number) they have been on – so you can self-report if you were near them. But mainly they do the shoe-leather work as the mainstay.

****

We concluded our chat with some reflections on history, an important factor that has been neglected by many authorities in planning for this pandemic – particularly remembering what happened with the Spanish ‘flu that followed the First World War.

The tragedy with COVID-19 is that things didn’t have to shake out the way they have in the United States. With a bit of knowledge and understanding of history, medicine, and epidemiology, combined with hard work, we could be looking at a very different scenario.

But the work is hard, and in the most recent Hong Kong case, public health authorities are testing and tracing more than 5000 contacts of just one index case. It is this level of effort that has limited the number of deaths to just four of the 7.5 million residents of Hong Kong.

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20 comments

  1. Bsoder

    Excellent, thank you. I really liked that the citizens decided to save themselves and no one got in the way. We have idiots in charge at every level and it’s not enough that they can’t get anything done, they actively work to make sure no one can get something done.

    Reply
    1. jrkrideau

      In Brazil the Federal Gov’t response under President Bolsonaro has been so bad that the drug gangs in the Rio favelas have been organizing to help.

      Reply
    2. Grayce

      Compounded, maybe, by an “official” disdain for mask wearing. This gets in the way of citizens uniting to keep COVID 19 from spreading. It only works if everyone is on board. Is there a lingering cowboy-macho-independence-day swagger in the US that blinds people to reality? Hollywood, get going and change the imagined face of courage.

      Reply
  2. Adam1

    At best the proposed intrusive technology would be an aid to good old fashion leg work because the technology isn’t smart enough to actually know the user or fill in the gaps for dead batteries or people who don’t own smart devices. The phone wont know when it’s been left home. It wont know when it’s been in contact with someone without a phone. I’m a figeter so when I work I take my phone any everything else out of my pockets… if I don’t they become play things. I can go the whole day and my phone may never leave my desk. I could have spent 50 minutes at a time next to multiple co-workers in meetings and those dumb phones never would have know the different.

    If someone had asked me I could have told them about meetings and people. Where the phone data potential could be valuable is in prompting me about locations I might have been and forgotten. That stop at the store 4 days ago to get milk and egg (which by the way I left my phone in the car while doing).

    Reply
  3. Darius

    I made a mask out of a Swiffer and some twine. Everyone wearing a mask in public shouldn’t even be a question. That it is subject to resistance and people who should know better are saying, well maybe, shows we’re just not serious about this and life in the US will be severely disrupted for a long time. Maybe that’s a feature, not a bug.

    If everyone is masking, but testing presents logistical problems, could widespread fever monitoring catch potential cases early?

    Reply
  4. Oh

    The people and government of the US are used to taking the easy way out on most things. An app appears to provide the easy way for contact tracing and also has the allure of technology (which most of the time doesn’t do what it promises). Shorts cannot always get you ‘from here to there’. How many times have we found out that the long way around turns out to be the right way but there’s no money in it for the technocrats.

    Reply
  5. VietnamVet

    This is an important post. Anxiety and fear are our way of telling us that staying at home and having everything delivered is unsustainable. If you leave home (unless in a hazmat suit), you are playing Russian Roulette with the virus and its hosts especially the unmasked ones as long as there are virus shredders free to move about in the population. Until there is no new cases in your jurisdiction for two weeks, getting within six feet of outsiders is a risk. Severe cases of the coronavirus are horrible. The actual number is unknown but a significant number of the infected must be hospitalized (roughly 10%). There are reports of severe secondary immune responses in children. Dismissing these risks is crazy. Expecting the pandemic to end by January 2021 when there is no vaccine yet and the USA does not have the infrastructure to make enough syringes and vials to inject every American is Magical Thinking.

    The lack of contact tracing and safe quarantine facilities in midst of a pandemic is murder, plain and simple. Mitch McConnell is rightly afraid of litigation. He and his corporate buddies are killers. But, this does not leave Nancy Pelosi off the hook. Daily, the death of thousands of Americans are due to political inaction on reconstituting a national public health system to test, trace and isolate the infected. Americans will never be safe until Democracy is restored and every American tested and the ill are quarantined. Instead, Andrew Cuomo’s and Google’s Eric Schmidt’s “Screen New Deal” will save the plutocracy with a scheme that is the exact opposite of public health. It will allow the pandemic to cull the unfortunate while the productive are surveilled and securely locked away from the contagion working in safe sites in front of connected LED screens.

    Reply
  6. PlutoniumKun

    Thanks for this – its also a useful reminder that successful responses to the virus is far more to do with deeper structures than who is in charge (the NY Times again today has one of its idiotic ‘why women leaders are better’ articles, including of course Carrie Lam as a ‘success’). In most cases, the most successful countries have been those who had good societal buy-in, along with a very professional core of public health professionals. The best thing for leaders in this case has been to not get in the way (clue for Boris).

    Reply
  7. ltr

    Carrie Lam, Hong Kong’s chief executive, led the government response to the Covid-19 threat and the response as the data show was splendid. The governmental response in a range of cities on the Chinese mainland beyond Hubei Province was similarly adept. Macao showed a similar adept governmental response.

    Reply
    1. OutofWACC

      Lurked here for a while but had to register just to debunk this attempt at whitewashing.

      Carrie Lam didn’t lead shit, the best thing one could say about her was that after her usual bout of stupidity she came to her senses in time and deferred to the (surprisingly competent) local health authorities for the response. Realistically given how fast the general population collectively wore masks and slathering themselves in hand sanitizer (2003 SARS PTSD runs deep), infection rates were going to be more Tokyo than NYC even without a “good” response.

      The thing that really surprised me out of all this was Singapore, one could sorta understand the Western countries (blinding following WHO) not being totally on board with the whole masks thing, but you’d think SG with its predominantly Chinese diaspora, and bad memories of SARS, would get the memo and encourage mask-wearing all the way.

      Reply
  8. Don Utter

    Excellent article to show what is possible and the snags in our systems.

    This article might have been posted before, but because of so much crap out there, worth posting again.

    A data doctor from UC SF

    Despite the Opposition of Some, The Science is Clear: Masks Stop the Spread of Coronavirus and should be Mandatory

    The article does not say that masks alone can STOP the virus

    I’m a data scientist at the University of San Francisco and teach courses online in machine learning for fast.ai. In late March, I decided to use public mask-wearing as a case study to show my students how to combine and analyze diverse types of data and evidence.

    Much to my surprise, I discovered that the evidence for wearing masks in public was very strong. It appeared that universal mask-wearing could be one of the most important tools in tackling the spread of COVID-19. Yet the people around me weren’t wearing masks and health organizations in the U.S. weren’t recommending their use.

    I, along with 18 other experts from a variety of disciplines, conducted a review of the research on public mask-wearing as a tool to slow the spread SARS-CoV-2. We published a preprint of our paper on April 12 and it is now awaiting peer review at the Proceedings of the National Academy of Sciences.

    Since then, there have been many more reviews that support mask-wearing.

    On May 14, I and 100 of the world’s top academics released an open letter to all U.S. governors asking that “officials require cloth masks to be worn in all public places, such as stores, transportation systems, and public buildings.”

    Reply
    1. JeffK

      @DU: I agree that making mask wearing needs to be a public health policy but I am concerned about two things. Learning (gathering evidence) about mask efficacy has taken some time. Even the WHO, in late January before their declaration of pandemic emergency, was saying that cloth mask wearing might increase a persons’ chances of contracting the disease because it gave them a false sense of security and handling the used mask might be a source of infection. In addition, they were aware that N-95 masks were in short supply and they they needed to be available to first-responders and health care workers on a first priority basis. They have since changed their messaging. Similarly, messaging about transmission through droplets and surfaces has been refined in these few months with new studies. While this learning process is completely legitimate, there are social/political elements in American culture that use this change in message to discredit the scientific community and ‘experts’, as if they really don’t know what they are doing and they are fumbling around at the public’s expense and well being.

      While I understand and appreciate the peer-review process, and acknowledge that a publication in PNAS is certainly impactful achievement in academic circles, the hard work (harder than the experimental design, logistics of data collection, and analysis) will be to translate evidence into enforcable yet TEMPORARY public policy, and to convey this new evidence as part of an ongoing learning process by a research community made of smart and flawed people. Perhaps a free ‘Don’t tread on me’ flag face mask available with purchases made at all gun shops won’t need the endorsement of the “world’s top academics”. Clever branding and merchandising might go farther in stemming infections than a manufacturer claiming that the mask was “approved by 100 of the world’s top academics”. Heck, there are MAGA face masks, (thank goodness ?). With the amount of distrust in public officials among the more tribal elements of our society, scientific validation of mask efficacy may not resonate to the point of compliance. For many (not me) it’s not all about evidence-based reasoning.

      I rode a 40 miler on my bike on a public space paved trail yesterday. I probably passed 150 people. Only a dozen including myself were wearing masks.

      Reply
      1. steven

        @JeffK – From everything I’ve read, e.g. Experts’ 7 best ideas on how to beat Covid-19 and save the economy,

        …the evidence seems to indicate that outdoor transmission is not, in practice, a huge problem. A detailed study of public outdoor spaces in Wuhan, China, found “undetectable or very low” levels of virus everywhere they looked. A study of more than 1,000 confirmed Covid-19 cases in other Chinese cities could only document one case of outdoor transmission.

        I am all for masks in confined spaces and would even consider wearing them in circumstances similar to those you describe if presented with evidence they are genuinely necessary, even if only one out of a thousand times. The facts seem to suggest otherwise.

        I am open to evidence (not just theoretical possibilities) to the contrary if you have any?

        Reply
        1. JeffK

          @Steven – As I said, it’s not all about evidence-based reasoning. There were lots of 20-30 something joggers and children on the trail. MY FEAR is (was) the asymptomatic jogging super-spreader who is exhaling more than the usual amount of droplets in a vapor I might be riding through. I don’t want to be that one-in-a thousand odd case because I am in a vulnerable age-class. I am aware of the studies and facts about outdoor transmission, and the unlikelihood of virus contact given the greater amount of wind dispersion. I’m not willing to roll the dice if I own and am willing to wear protection.

          Reply
  9. RonD

    Hong Kongers can do anything!! I love that place. When the Zombie Apocalypse comes I suspect Moscow and Hong Kong will be the two holdouts :-)

    Reply
  10. Andrew Thomas

    The personal interview, trace and test is the only reliable way to do this. And, at least, the Hong Kong government didn’t get in the way by effectively enforcing the mask ban, which was tied to their use by violent protesters. As for civil liberties, we are already at the point where we have no right of privacy that goes beyond the ability to access birth control (Griswold v. Connecticut, USSC, 1968) and abortion, to some extent (Roe v. Wade, 1973) Roe is about to go away, and any reasonable expectation of privacy that actually matters to the PTB was long ago extinguished in the manner described by Edward Snowden. The apps that will supposedly replace the shoe leather approach won’t be suitable for their announced purposes, but they will make a lot of money for their developers, which is the real purpose for them. As for their effect on civil liberties, it will be to regild the lily. That ship has long since sailed. If you bring enough attention to yourself that what you say is seen as a threat, you are toast. The only civil liberty guaranty left is, in other words, expressing one’s opinions and inconvenient facts, but being seen as harmless. Unless spending money is regarded as a civil liberty, and that is hardly a threat.

    Reply
  11. pricklyone

    I have yet to see a mask for sale at any retail outlet. If I am to wear one, by dictat, they need to make them available for sale. And not at $4-5 for daily use, either. That is more than my food budget.
    There may be some case for “face coverings”, but they are barely more effective than nothing.
    I keep hearing “just use a bandanna, or scarf” as regards the legal requirement imposed by the state gov. Who has such a thing on hand, and why? I have never had a bandanna in my possession, and my late significant other had none, either. As to scarves, are you wearing winter scarves as face protection? I have one heavy winter item, totally unsuitable to the climate this spring. Women may be better supplied than us males, in this regard(?).
    Whenever I seek info from the many articles, they all are “making masks from household items”, none of which have ever been in my household over the last 60 years, and are unobtanium at retail, especially when they cost more than my food allowance for the week.
    Now, I am basically a hermit, and only venture out for food/necessaries every few days. I have been social distancing for 5 years! I would gladly wear a mask, if it available and affordable to me.
    So far not the case.
    I had some super cheapie paper “dust masks” but the elastic has degraded, and they do not fit correctly, at any rate.
    I have a beard, and would be willing to shave it, if I could obtain a mask which would make doing so worthwhile, but nothing out there because needed for medical staff. From what I saw online, the prices went up by an order of magnitude, while they were still available. By the time they changed their minds,and we had to wear “face coverings” all the useful items were long gone.
    I used to do some orders on ebay, and such. Twice in 2 years I had to have CC company reissue new account number (CC number). I don’t use CC much, now, except for gasoline purchases, and I watch carefully for trends in skimmers, BTW.
    I admit to having underestimated, early on, the trajectory of this disease, and I was limited in being able to provision ahead as I had no funds.
    Thanks for letting me vent.
    Try to be safe out there…

    Reply
  12. John Zelnicker

    This is a great example of the advantages of thinking collectively instead of individually, as well as the power of grass-roots organizing. Of course the speed of execution was made possible my the pre-existence of the organizing infrastructure from last year’s protests.

    The lesson to learn is that developing such an infrastructure gives the people the ability to respond to various threats to their well-being, be they political or medical or otherwise.

    IMNSHO, the progressive/radical left in the US should be building this infrastructure now with Bernie’s “movement” taking the lead.

    Hong Kong’s experience also exposes the moral bankruptcy of “American Rugged Individualism”, translated as “I don’t give a sht about you, I’ll do what I damn well please.”

    Reply

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