Contact tracing has been used for decades to fight Tuberculous, Smallpox, Ebola, and STDs. Despite the vast success of contact tracing in eliminating the world’s most dangerous diseases, it has always been a delicate dance between public health and personal privacy. New smartphone technology for contact tracing raises the big-brother hackles of people who distrust the data practices of the big corporations building these apps.
As stay-at-home restrictions in the United States continue to be lifted and people increase their commingling, many scientists believe it will result in COVID-19 flare-ups. The CDC hopes vigilant testing and contact tracing will douse the flare-ups before they become full-fledged conflagrations.
The potential of sophisticated contact tracing apps to help eradicate COVID-19 intrigues me. I’m a believer in using technological innovation to solve the world’s problems. With this in mind I decided to learn the basics about contact tracing by enrolling in Johns Hopkins epidemiologist Emily Gurley’s free Coursera COVID-19 Contact Tracing Course. I began the class believing new technology will solve the problem but what I learned convinced me I was wrong.
Common sense is the key ingredient in contact tracing. If someone is diagnosed with COVID-19, aka, a “case,” and is isolated from others, the people who encountered the case during their infectious period, aka “contacts,” should be quarantined from others. The Coursera course goes into detail about infectious periods, who is considered a contact, computing lengths of isolation and quarantine, and myriad other important details many of us may not know. This is the beauty of contact tracing – it’s a practical approach to corralling illness imbued with facts. Learning about contact tracing in this course takes less time than a couple of modern day movies – it’s closer to one movie if your choice is The Irishman.
As I was completing the course, in true 10xPrinciples fashion, I wondered what makes a superb contact tracer? The course provides several entertaining Goofus and Gallant, (the Eddie Haskell and Wally Cleaver of Highlights Magazine), comparisons showing the wrong way and the right way to conduct case and contact calls. A section of the course is devoted to building rapport on calls, how to productively ask questions, and how to show empathy. Dr. Gurley notes, “Contact tracers are equal parts detectives, investigators, social workers, and therapists.” This sounds very much like the job description for a Product Manager. It’s possible to teach a Goofus to say the right things but teaching empathy is nearly impossible.
Contact tracers learn strict rules about confidentiality and privacy, and balancing them against the public good. For example, test results are confidential, used only for the public health investigation, and are not shared with anyone else. Furthermore, personal information about cases and contacts is kept private – those who have been exposed will be informed, but will not learn the identity of the case. Contact tracers are trained to ignore any personal information revealed by a case or contact, e.g., “I’m afraid to seek social services because I’m undocumented,” unrelated to the public health.
The United States is in a dark period with respect to immigration, racial relations, and income disparity. A municipality may implement a stellar testing and contact tracing program. Regardless, without buy-in from the community, the program’s foundation will have cracks. Some sick people are understandably wary of testing or being traced. Realistically, even if counties wage multifaceted public relations campaigns to dispel perceived fears, there’s no way to achieve widespread participation until societal changes rebuild trust. This means parts of a community may not receive time-sensitive and valuable contact tracing services.
The chart below illustrates the very short time window before a person in proximity to a case may become infectious. On average, people exposed to COVID-19 display symptoms after five days and become infectious two days before exhibiting symptoms. This very narrow time window before infectiousness makes contact tracing urgent.
Given the time sensitivity of notification, a potentially large number of people to inform, and an overworked contact tracing team, technology may provide some badly needed assistance. Although flashy tracking apps in the works from Google and Apple are receiving the lion’s share of attention and trepidation, here are a few less intrusive technologies already used by contact tracers:
- Electronic Case Reporting – A database of COVID-19 tests with automated reporting of positive results to contact tracers. This enables contact tracers to learn quickly about who needs to be called.
- Tracking Symptoms – Among the important contact tracing responsibilities is recognizing symptoms in cases and contacts that may require medical treatment. Additionally, symptoms are tracked to determine when infected people can end their periods of isolation. Typically, a contact tracer makes time consuming daily calls to cases in isolation or contacts in quarantine. An app that collects information via a text message questionnaire doesn’t entirely replace person-to-person discussion, but can certainly facilitate information gathering.
- Support for people in Isolation and Quarantine – Some people may require help getting food/medicine. One solution is to send text messages to remind them they’re still in isolation and what it means. These messages also provide information about where and how to get support; this is especially important since assistance is often not needed at the outset of a quarantine, but may become necessary later.
In a The New Yorker, 6/8/2020 article, Elizabeth Kolbert writes that Iceland, a country of 364,000 (half the population of Denver), had a large per-capita infection percentage and followed a textbook-perfect playbook that included:
- Acquiring sufficient Personal Protective Equipment prior to their first case
- Assembling testing and tracing teams prior to their first case
- Rigorously enforcing quarantine periods for anyone entering the country
- Expanding testing and tracing teams as caseloads grew, ensuring everyone in contact with cases promptly quarantined
- A troika of officials, including the Director of Emergency Management, Chief Epidemiologist, and Director of Health, working closely to give apolitical briefings to the public every day
Iceland has all but eradicated COVID-19 and they accomplished it without the large scale shutdowns in other countries. In addition, Iceland’s infection fatality rate is a mere .55% compared to the United States current rate of 5.82% [World Health Organization, 6/4/2020]. Iceland is the Gallant to the United States’ Goofus. Interestingly, according to Bobbie Johnson in the MIT Technology Review, 5/11/2020, even though 38% of the population downloaded a tracking app, a remarkably high penetration percentage for a non-state mandated app, Iceland found little use for this tracking technology in its contact tracing. Iceland determined there was no technological silver bullet to be found. Instead, public health officials relied on tried and true protocols, organizing to support large testing and manual contact tracing efforts.
Yes, Iceland is minuscule compared to 330 million in the United States. However, New Zealand successfully pursued an eradication plan. So did South Korea. Although New Zealand implemented a series of lock-downs and South Korea submitted to state-sponsored digital tracking, these responses mirrored Iceland’s, placing science, leadership, and careful language at the forefront.
Many people in the United States are justifiably suspicious of large corporations offering COVID-19 tracking apps. These apps track the proximity of phones (people) to one another and the duration of exposure. A large-scale buy-in is required for these apps to reach their potential as well as widespread COVID-19 testing, neither of which will likely occur. It is altogether too easy to imagine an employer using a tracking app for nefarious purposes, e.g. an overweight employee tracked visiting McDonald’s receives an email gently informing he’ll be charged a higher insurance premium if he doesn’t lay off the Big Macs and lose weight.
Rather than addressing pressing scientific problems by recommending behavioral changes, our leadership assiduously denies the issues. Climate change is one example of this denial. COVID-19 is another. In an administration that rejects science, the public shouldn’t be surprised to hear a president grasp at unrealistic suggestions like injecting bleach to neutralize COVID-19. In all likelihood, James Dyson will be asked to invent a cordless vacuum to suck Carbon Dioxide from the atmosphere.
Unfortunately, we have no magic solutions for COVID-19. At best, the Apple/Google tracking apps gain widespread penetration and become another instrument in a contact tracer’s tool belt. In the absence of a vaccine, old fashioned testing and contact tracing are the best avenues for the United States to pursue a containment plan. This plan also requires science-based communication, national leadership, and societal cooperation, all of which, sadly, are in short supply.