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.”