By Jerri-Lynn Scofield, who has worked as a securities lawyer and a derivatives trader. She is currently writing a book about textile artisans.
After weeks of voluntary national lockdown, some states are easing their social distancing requirements.
The new magical thinking for U.S. management of this pandemic: contact tracing.
Michael Bloomberg has made a significant investment in this strategy. According to Wired:
As with testing and acquiring personal protective equipment, the federal government has left the challenge of recruiting and training an army of new contact tracers up to state and local public health departments. Absent a national plan, epidemiologists at the Johns Hopkins Bloomberg School of Public Health stepped in to create a crash course that they hope will help public health departments rapidly expand their workforce. Their first remote students will be the thousands of people who’ve already applied to be contact tracers in New York state, the American epicenter of Covid-19. “To be honest, we’ve never done contact tracing at this scale in our living memory,” says Emily S. Gurley, an infectious disease epidemiologist who is leading the program. “So a lot of this is brand new.”
In late April, New York Governor Andrew Cuomo and former New York City Mayor Michael Bloomberg announced plans to hire as many as 17,000 tracers for the state. Bloomberg’s philanthropic organization donated $10.5 million to the effort. Some of that money went to funding the creation of the Johns Hopkins course, which—in addition to further training—will be a requirement for anyone hoping to be hired into the New York tracing corps. Cuomo told The Washington Post this week that the online course is a “key component of our program that will provide tracers with the tools to effectively trace Covid-19 cases at the scale we need to fight this pandemic.”
Incredibly, U.S. states are only now rolling out contact tracing programs, many months after places that have successfully managed the pandemic: Hong Kong (4 deaths, 1056 cases), South Korea (11,065 cases, 263 deaths), Taiwan (440 cases, 7 deaths), Thailand (3031 cases, 56 deaths), Vietnam (320 cases, 0 deaths) – have run test, trace, and isolate programs.
I have written three previous posts (see here, here, and here) on what has made Hong Kong’s approach so successful. For each of these, I’ve been able to draw on the wisdom of my old Oxford friend, Dr. Sarah Borwein, a Canadian who has practiced medicine in Hong Kong for fifteen years, and before that, in Beijing. Densely-populated Hong Kong has 7.5 million residents, and so far, has recorded four deaths, and just over 1000 cases, despite a slow and bungled initial response by chief executive Carrie Lam and by eschewing misplaced reliance on any techno-fix apps that carry significant risks to civil liberties (see here, where I discuss these points in detail; and this FT article discussing the limitations of contact tracing apps, Coronavirus contact tracing apps struggle to make an impact). And I turned to Sarah again to discuss some necessary conditions for successful contact tracing.
Flaws in U.S. Contact Tracing
Despite Cuomo and other US leaders waking up to the merits of a contact tracing strategy, there are at least three flaws inherent this late Damascene conversion.
First, the United States has simply left it too late to join the contact tracing party. Its botched testing strategy means COVID-19 had spread widely, throughout many communities, and public health authorities are blind as to what they were dealing with. According to the FT
Restrictions on testing narrow the options. “Once you get to one per cent prevalence in any community, it is too late for non-pharmaceutical interventions to work,” says Tom Bossert, who led the since-disbanded White House pandemic office before he was ejected in 2018 by John Bolton, Trump’s then national security adviser.**
Second, there is too wide a gap between when the contact is identified, and then informed of the possible exposure. During that gap, the victim may be asymptomatic, and spreading the virus. According to Technology Review, in an article with a headline that minces no words Why contact tracing may be a mess in America:
A study published on May 1 in JAMA Internal Medicine, tracking the first 100 cases in Taiwan, found that people are most infectious before and within five days of the onset of symptoms. That adds to a growing body of evidence that people with minimal or no warning signs like fevers and coughs are a major vector of the disease.
That underscores the critical importance of contact tracing. The very goal is to identify people who don’t know they’re infected and encourage them to quarantine themselves before they unwittingly infect others. But it’s hard to identify and trace all the cases out there if people aren’t sick enough to know they should get tested, and it means contact tracers need to move incredibly fast to get to people before they’re already spreading the virus.
“I say you need to find people and isolate them within four days of exposure, if you’re going to make a dent,” says George Rutherford, a professor of epidemiology at the University of California, San Francisco, and principal investigator on California’s contact tracing program. “It’s probably even three.”
And I find my third point to be incredible. The U.S. contact tracing programs trace, but once identified, they do not automatically test the contact to determine whether s/he has contracted the disease. S/he is told about the contact with a known COVID-19 victim, but then it’s left up to person to decide whether or not to submit to a test. And as to getting tested, tests remain in short supply in many areas. Compare this to Germany, South Korea, and Taiwan, which provide access to immediate results, including drive-through testing systems.
Over to Technology Review:
Successful contact tracing efforts also require people to accept calls and heed advice from complete strangers.
Unfortunately, years of robocalls and telemarketing have conditioned many Americans to ignore calls from numbers they don’t recognize. Jana De Brauwere, a program manager with the San Francisco Public Library who is working with the city’s contact tracing task force, says that at least half the people she calls simply don’t answer. Others hang up once she starts asking for personal information, like addresses and dates of birth.
Even if contacts do take the call and stay on the line, there’s the separate question of whether they’ll follow the advice to get tested or voluntarily place themselves in quarantine. [Jerri-Lynn here: my emphasis]
To expand on that point, let’s turn to Wired:
Once they have this list, tracers try to call every person or business on it, explaining that they have been exposed to someone who tested positive for Covid-19. They’ll encourage those “contacts” to self-quarantine for 14 days to prevent any further spread. For the next 14 days, those tracers will stay in touch—via text, email or the phone—to see if anyone is developing symptoms and help them through any difficulties they’re having with staying isolated. Some localities are using apps to help people in isolation automate some of their symptom reporting, and others use virtual check-ins with the tracer. But phone calls and texts aren’t always enough. Officials from multiple public health agencies told me they hope to be able to send people out into the real world to track down hard-to-locate individuals once their agencies have acquired the appropriate masks and other protective gear to ensure the tracers can do it safely.
Yes, I realize the tests are not perfect. But they are the best tool we have. So, what should happen is that contacts are traced, quickly, and then tested immediately, and given quick results. Other countries can manage this task, some with far more meager resources than the United States currently spends on health care. So. why can’t we?
Once identified, those that are positive must be quarantined, or strictly isolated. And that leads us to a larger problem.
Consequences of Testing
An even bigger flaw in these programs is that they fail to make anyone – either prospective patient, or the government/health authority – face up to the consequences of testing. I’ve discussed this with Sarah, and we both agree in managing a pandemic of this type, with a highly contagious virus, there will be civil liberties implications. (Note these are different from the civil liberties implications of hoovering up data via an untested app, with no limits imposed on the use of that data, and that’s not as useful to pandemic control as what Sarah describes as old shoe-leather epidemiology and which we discussed further here.)
Now, no one wants to be quarantined. Some people will not comply without being tracked or forced. But strict isolation is necessary to stem the spread of this highly infectious disease: you don’t bullshit with this virus. And Sarah agrees, “As you said, not a virus you can bullshit. It will find every chink in your armour”.
She points out that “testing alone isn’t the answer – you need your population to accept the consequences of testing.”
This is a key point. Americans can not even agree on the wearing of masks; how can we possibly get some to accept the consequences of testing?
Consequences are, however, a two way street. The person tested agrees to accept the consequences of testing. That means quarantine, at a safe, functioning, hygienic facility. I don’t rule out that self-isolation could work. But it must be true isolation, perhaps enforced via a tracking bracelet. Backed up by threats of real penalties for people who jump quarantine or isolation: fines, prison terms? And with the delivery of food and medicines, and if necessary, assistance in locating shelter.
Sarah notes that the quarantine must be strict in order to work:
With a virus as transmissible as this one, that transmits well from asymptomatic and presymptomatic people, quarantine has to bestrictly enforced to work. Otherwise too many people exempt themselves. Quarantine is for the healthy exposed after all. So they feel fine, and many get fed up with it or won’t accept it unless there are consequences – tracking bracelets, fines, prison terms…..
And if you don’t isolate every case, they end up very efficiently transmitting to their households and beyond. That’s why places like Hong Kong, Taiwan and Singapore, not to mention China, hospitalize every case. Singapore has temporary facilities for the isolation and monitoring of the large number of mild cases they have in their foreign domestic workers. Not home isolation.
I’m just not sure of this point, but I don’t know enough about the science or the medicine to offer an informed opinion as to how home isolation, well supported and strictly enforced, could be viable.
(I am not going to discuss the constitutionality of mandatory quarantines in this post; I refer interested readers to this Politico piece. I will just mention that it is an issue that will have to be addressed in future, especially as the U.S. has so mismanaged the COVID-19 pandemic. Most countries that have successfully managed the COVID-19 pandemic have done so by imposing strict self-isolation or quarantine requirements.)
Yet I now want to move onto another important point: the consequences don’t stop there, with patients. The government/health care system has its own reciprocal consequences of testing that it must accept. The health authorities should monitor the quarantined/self isolated patient. At present, this is not done. Shockingly, according to the New York Times, ‘I Wish I Could Do Something for You,’ My Doctor Said:
One thing I learned is how startlingly little care or advice is available to the millions of Americans managing symptoms at home.
In Germany, the government sends teams of medical workers to do house calls. Here in the United States, where primary care is an afterthought, the only place most people suffering from Covid-19 can get in-person care is the emergency room. That’s a real problem given that it is a disease that can lead to months of serious symptoms and turn from mild to deadly in a matter of hours.
And crucially, when necessary, the government must see to it that the patient has access to medical care. Bernie Sanders has called for the existing Medicare system to cover the costs of COVID-19 care. I think it will be impossible to stem the pandemic as long as people are worried about the costs of their care. According to Common Dreams:
Countering a proposal from Democratic congressional leadership to subsidize private health insurers, Sen. Bernie Sanders on Friday led a group of progressive lawmakers in introducing a competing bill to leverage the existing Medicare payment infrastructure to cover all out-of pocket health costs for every person in the country during the coronavirus pandemic.
“During this public health crisis, we must make sure that everyone in America is able to receive all of the medical care they need, regardless of their income, immigration status, or insurance coverage. No one in this country should be afraid to go to the doctor because of the cost—especially during a pandemic,” Sanders (I-Vt.) said in a statement. “The American people deserve an emergency healthcare response that is simple, straightforward, comprehensive, and cost-effective.”
“We should empower Medicare to pay all of the medical bills of the uninsured and the underinsured—including prescription drugs—for the duration of the coronavirus pandemic,” he added. “When so many people in this country are struggling economically and terrified at the thought of becoming sick, the federal government has a responsibility to take the burden of healthcare costs off the backs of the American people. The legislation we are introducing today does just that.”
Is it any wonder that the United States is showing the highest number of COVID-19 casualties – by a long shot – given our dysfunctional system for allocating and paying for medical care. Currently standing at over 1.5 million confirmed cases and nearly 90,000 deaths.
Now, let me pick up on a point Shamanic Fallout made in yesterday’s comments on Links: some people are the sole caretaker for a child, or elderly or disabled person. Well, if we want to defeat this scourge, we need to provide care when the caretaker is isolated or taken into quarantine. Otherwise, the system just won’t work.
Probably, in this country, why, if you had say a home test and tested positive, many would not disclose. Where are you going to go? Get dragged out of your house to some isolation unit? Go bankrupt even if you have ‘insurance’? And what about some one like me? I have a five year old daughter and her mom, my wife, died two years ago. I am her only potential care giver. If I were positive what do you think I should do? If I were ‘isolated’ where would my daughter go? Is America full of these kinds of places? If they were I can’t imagine what they would be like. Not going to happen.
So, contact tracing as it is currently practiced in the U.S. – starting too late, with too big a gap between victim’s infection and tracing of known contacts, without automatic testing of those contacts once identified, and neither patient nor government/health authority forced to accept the consequences of testing – is a Panglossian panacea to COVID-19 spread. Contact tracing could be made to work, but not as presently designed. Readers will no doubt pick up on reasons the United States will not, even at this late date in the course of the first wave of the spread of COVID-19, take necessary steps.
So when the history of this pandemic is written, failed contact tracing will join the litany of mistakes the United States has made. And as William Burns, who was the most senior US diplomat, and now heads the Carnegie Endowment, was quoted as saying in the FT:
“America is first in the world in deaths, first in the world in infections and we stand out as an emblem of global incompetence. The damage to America’s influence and reputation will be very hard to undo.”
About people not answering phone: maybe cell phone carriers could give contact tracers a way to be identified as not commercial or scam call. Or maybe they could text and ask for return call.
But as you show so well, it is too late. Why on Earth could this have not been done in February and early March? How could New York, one of our richest and most sophisticated states, fail so hard?
Much as I follow the public health logic, this proposal is utterly negated in the presence of a failed state that exists only to maintain private fiefdoms of debt servitude.
Your cellphone? Already sold to the trackers and advertisers. There is NO reason to trust ANY number you don’t already know.
Health care? Just another trapdoor into inescapable debt servitude.
Fines and jails? Sorry, officer, I have no idea what you’re talking about.
The United States went into WWII with a population whose government had just been ACTUALLY helping everyone through the Great Depression.
This country is now going into the future with a population that knows exactly what they’re going to get if they “cooperate” with any arm of government.
Can’t fault them for refusing to play along. The prerequisites simply aren’t there. Haven’t been there for a long time now.
give contact tracers a way to be identified as not commercial or scam call. Or maybe they could…
send an eMail. An email address in addition to or in place of a phone number could take care of many of the issues noted.
AFAIK the only way to lock out scammers is to have a widely publicized phone number (or email address) for the contact tracing service. Then the client uses that number to call back to the tracing service. You cannot trust a contact address that a scammer gives you.
Then the system at the contact tracing service has to be able to connect the client with the tracer who’s handling their case. It doesn’t seem easy, but good systems people might be able to build something that works.
The whole cellular phone system is not secure. It’s fairly functional, and fairly affordable, but it ain’t secure.
Flip the phone issue around. Rather than give the robocallers a pass, how about strengthening the legislation against robocallers and enforce it? Several attempts have been made to outlaw robocalls, but Congress will not pass the legislation and law enforcement doesn’t even enforce the current law. The phone carriers are lax as well. If you started throwing robocallers in prison for life because we have to prtotect the integrity of our communication systems, then people might not be so reluctant to answer the phone.
Best practice favors the 1%, and more importantly the 10% “experts” employing the 1% as a scapegoat, to ensure false choices and no change to the status quo.
Why would one zip code determine policies for everyone else, and why would the 8% consuming most healthcare expenditures determine policies for everyone else?
Of course the experts want the sheep to repeat the mantra that we are all in this together.
All this make me feel all that more powerless.
And the more I stay at home, the more I hate humans.
American humans seem to be exceptional in many, many ways.
Be well everyone.
Excellent post, well worth a read.
All I can say is that if tests are not free, and treatment is not free (and in fact can bankrupt you, leaving aside reasonable mistrust of hospitals as systems, regardless of their dedicated personnel) then there are enormous disincentives to being traced, and to being tested.
Voluntary testing and tracing, then, will skew upward by income, when all the evidence is that the lower your income is, the greater your danger of infection.
Paid sick leave needs to be a part of track and trace. Otherwise, people won’t even report they are sick.
The hashtag on Twitter: TestTraceIsolate : needs to have Support added to it. As this article so thoroughly points out, the support part is crucial to make certain the Isolate part of that hashtag works. And so many otherwise alert people are not picking up on the crucial nature of the support.
For the Isolate part to work, again as so completely gone over here, 99.9% compliance has to be achieved, otherwise it does not work. Staying at home: except to get groceries, or do laundry, or visit family: *no*. Not. Going. To. Work. So Isolate and support have to be done in tandem.
I am seeing again and again as I review the news, (compulsively, as I’m 70 with three comorbid conditions) that education about the many aspects of this pandemic are crucial. Fear drives out the motivation to learn and leads, in too many instances, to bull headed intransigence on compliance with the CDC’s guidelines.
This describes all the reasons I have been skeptical of the standard test-trace -isolate mantra. American ideas of self-reliance/freedom leaves us with a big deficit in civic morality.
Good post. As to “I’m just not sure of this point, but I don’t know enough about the science or the medicine to offer an informed opinion as to how home isolation, well supported and strictly enforced. could be viable.”
It isn’t viable unless you live alone, have a cop outside your door, have whatever you need given directly to you, are checked medically every day. To complicated. Need a facility design for such. As we used to, when we cared about each other.
The criminal thing is it wouldn’t be that hard to come up with a quarantine program that would be tolerated by large numbers of Americans. Here’s my fantasy:
You check yourself into the Days Inn for 14 days. There’s a pair of National Guards-people on folding chairs at each of the exits. All the streaming services are free in your room. Adequate but unexceptional take-out food is delivered 3x daily, you bag your trash and set it in the hall. Federal law compels your employer to continue your wages and benefits if you were working while quarantined; there’s an associated Federal subsidy to cover this. If you weren’t working, and were on unemployment, your unemployment is extended for the duration of the quarantine, maybe longer. Everyone else gets a modest stipend, payable at the end of your stay, as a Government check, or even cash for the homeless/unbanked. Testing happens every 2-3 days. Someone checks in with you verbally 2x a day about your symptoms. There’s a portal you can get to on the overwhelmed WiFi that tells you what’s going on. If you worsen, you go to the field hospital/Covid unit at the hospital.
Doing this would be expensive, but if this thing bounces back in the fall with another wave the economic damage will dwarf this piddly program.
Let’s add some way to provide good child/elder care for those left behind when someone has to go into quarantine. Perhaps allow such quarantined people to designate their own choice of a substitute and guarantee the employment etc. of that substitute.
Also, let’s not forget we’d need to allow pets. I took the Johns Hopkins course and wondered over and over how large numbers of people were going to isolate. Most residences do not have separate bed rooms with their own bath rooms. My husband has three co-morbidities and every time I have to go to the store it feels like a roll of the dice. If I got it and it incubated for even just 2 days he’d surely have it before I could move out.
I think if the government agents/medical people actually deeply cared about potentially infected people and saught to help them as they are, things would be quite different. If there were no need to work to pay for rent, no food insecurity, no burden of debt bondage as a result of a visit from a tracer, we might see different responses. If the quarantine place were actually comfortable, functional, had reliable and clean food/water and some outdoors space to enjoy, and if quarantine/tracking weren’t equated with police arrests/brutality, people may respond differently.
It’s as if this country doesn’t know how to not be brutal to each other, or how to actually offer meaningful support to the individuals involved so doing what’s best for the public welfare is easy for the individual.
Great breakdown of what it takes to make trace-test-isolate work, and the challenges. In many California counties the numbers of cases are low enough that such a program could work if it were funded and managed properly. Trump and the Republicans pulled a bit of a fast one in leaving the state and local governments “free” to choose their own responses, shifting much of the cost to them which they have limited capacity to bear.
As far as people not answering phones, here in California many wildfire alert systems have been implemented in recent years to warn residents of imminent danger from fast moving fires. These involve texts or calls to phones. Maybe that approach would work, if it were publicized properly. We also have “AMBER” alerts for child abductions, which is a national system. Alerting people is only one step in the process though.
Thanks for the post but (if there is one?) I would like to see something that describes what WILL work for the U.S. at this late stage of the game – even with all the screw-ups and institutional defects. This post still seems to be definitive: We need an immediate five-week national lockdown to defeat coronavirus in America From everything I’ve read pandemics are like forest fires; after a while deprived of fuel they burn out by themselves. There are probably millions of people in congregate living situations who have already been incarcerated for more than five weeks. For everyone’s sake, this needs to be brought under control ASAP – along with the ‘open-er-up’ virus denialists and the politicians encouraging their hallucinations.
This mismanaged pandemic is just a taste of what is in store for the country and the world if it allows itself to continue to be governed by the ignorance and delusions instead of the laws of science (and I include medicine) upon which the lives of billions of people depend.
IIRC, if we got to 80% masking, that would work.
Such a simple thing, not costly, and the home-made options suffice – but rather than set an example, Trump continues with his mask-free photo opportunities.
Interesting. It might take a little longer and a few more old people would have to die (that might include me BTW). But the Trumps of the world wouldn’t lose quite so much money on their investments; IOW it might be politically feasible.
So there you have it freedom-lovers – a choice!
A little feedback regarding social behaviour. In Australia we tried mandatory 14day HOME quarantine for all people returning from overseas. That was reasonably effective however there were sufficient numbers of people flouting the quarantine that the authorities though another approach was needed. So instead they introduced 14day monitored HOTEL quarantine for returnees. Sure it probably wasn’t ‘cheap’ but the hotels were empty and it save a significant amount of spread.
When you have many cases this is no longer possible and also has negative effects. Using hospitals as quarantine centres for non serious cases has numerous issues. There is a reason why these were a thing:
I agree. Months later, I am still upset that the USA federal government is not testing, tracing and isolating the infected to combat coronavirus. It is not a coincidence that Russia, United States and the United Kingdom failed or China, Vietnam and Cuba are succeeding. A question is what did Australia and New Zealand do right? I am no expert on these nations but two hints are Australia hired 20,000 laid off Qantas employees to do contact tracing and the comment above about their using hotel rooms to isolate the infected. Also, the South Pacific nations are close enough to Asia to be concerned about transmission of diseases and the public health systems there still work. Only functional governments can control the spread and halt a novel disease with no human immunity through old fashion public health practices.
Corporations will only develop treatments or vaccines that are patentable and profitable. The US federal government is incapable of mounting a public health campaign. The CDC is sidelined. Crony corruption must end and democracy restored before people will trust government again. They will go into quarantine if it is a safe location and they are paid. If forced, they won’t. Already, the lockdown is collapsing. Only well-off prudent or completely isolated communities will avoid the upcoming spike in infections and deaths.
The USA could still control the pandemic even though it is highly contagious and in places, like New York, the percentage of infected is already above 20%. But it is hugely expensive and disruptive. I don’t know if a conscious decision has been made or it is just ingrained arrogance, but the American Elite have decided to wait for a pharmaceutical response and have taken the position that it is of no consequence if up to a million Americans die.
Hey VietnamVet, Here is a video I linked to the other day which compared the responses of New Zealand and the United Kingdom and specifically their leaders – Jacinda Arderne vs Boris Johnson
Here in Oz, the Prime Minister gets the credit internationally for having a good response but in reality, it was our Premiers (the “Governor” for each State) which took the lead. I imagine that in the US, what sort of Governor you have for your State determines how well you deal with this pandemic.
Great video, I watched it when you first linked to it. Certainly worth 3 minutes of anyone’s time.
It is a great 3 minute video and well worth watching! Thanks for posting.
As an Australian I’ll try to answer this question.
-pragmatism rather than politics
-a decent health care system (though largely so far this hasn’t been needed)
Luck played a big part I believe. There are plenty of European nations with similar advantages that Australia has.
Our health and economic response was pragmatic and followed the advice of the ‘experts’. Australia’s inept Prime Minister was slow in responding unlike New Zealand, but we still got there thanks to pressure from the states. And while Australia’s PM was inept, the eventual response wasn’t. While mistakes were made the general reaction was pragmatic.
The US is a litany of failure. The fragmented public service is a bad start, not to mention the insane health care structure. Though that could have been mostly fixed with appropriate leadership from the top. Sadly that was lacking too.
I don’t consider Russia to have failed. They have been getting a lot of press lately because the virus accelerated there lately and the number of confirmed cases is high, but as I write, they have 2837 deaths vs. 93533 for the US or 19 deaths per million population vs. 283 for the US.
Thanks, Jerri-Lynn for your continuing coverage of these issues. Your friend, the doctor, is quite an excellent resource.
I noticed that at least half of the comments above (17 total at this writing) make one point or another about how the culture of the US is antithetical to successfully controlling the virus.
Once again, American Rugged Individualism(tm) is shown to be morally bankrupt.
All they have left is the printing press, so they have to put the pedal to the metal on rolling out the surveillance state.
If people want to alter their genetic code, that’s their business, but why must they force others to do so. So much for voting with your feet. Poor kids.