How to Get Contact Tracing Right

The states that are succeeding are relying on people, not programming.

It’s been more than five months since the novel coronavirus was first detected in the United States. Even as the pandemic continues to spread—the U.S. recorded a single-day record of 70,000 new cases over the weekend—some states are still returning to something resembling normal. Most have cautiously re-opened restaurants, gyms, and retail stores with safety precautions in place; a number of GOP-controlled states have imposed far looser restrictions.

But as more Americans emerge from lockdown—and cases keep surging now that stay-at-home orders have been lifted—governors and mayors are trying to hone the two main measures that are needed until a vaccine or effective therapy is produced: expanding testing capabilities and contact tracing, which entails identifying people who test positive and tracking down anyone they’ve come into contact with.

The first component should have been easier, but the Trump administration set the country back when it failed to produce mass testing after first learning of the pandemic in January. According to the Washington Post, it wasted more than 70 days before addressing the disease. As a result, states were left to fend for themselves to obtain the necessary supplies.

But contact tracing, it turns out, may be even more complicated than testing: It will require state and local governments to design and implement working systems in a short period of time, and then to hire and train staff that can implement those systems. It will require cooperation from a population that has grown increasingly distrustful of government-collected data. And it will require coordination between states and municipalities, especially since there is no cohesive national entity leading the effort.

Unfortunately, state-level contact tracing does little to track people who move across multiple states and regions, or account for immense disparities in public health resources among different states. Equally disconcerting: As state revenues are expected to dip by 20 percent this summer, hiring a new public health workforce is significantly more difficult for states that already lack expansive public health funding.

That has left states with a daunting task, especially since enacting a contact tracing program is something most haven’t done before. Some of them have relied on digital technology to help. Alabama, South Carolina, North Dakota, and Virginia are partnering with Apple and Google to develop their own exposure notification apps, which would allow people who test positive to enter who they have been contact with. Anyone who signed up and was entered in by someone who has been infected gets notified. Utah and South Dakota have designed similar software with the help of smaller tech companies.

Those efforts, however, have already run into hiccups. For example, less than two percent of residents in Utah downloaded the state’s Healthy Together app as of late May. Meanwhile, a recent Washington Post-University of Maryland survey that found three out of five Americans either can’t or won’t use contact tracing apps. That suggests this low turnout reflects a broader national sentiment.

The good news is that some states are showing a better approach. New York has eschewed technology and is focusing on contact tracing the old-fashioned way. This means that physical workers, not technology, are the ones doing the job of discerning who comes into contact with positive cases. New York City has already hired 3,000 contact tracers, many of whom live in the neighborhoods they’re working in, to reach out to people who’ve tested positive over the phone and in-person. The city’s initiative has shown early success: As of June 16, it had reached 94 percent of all new positive cases.

New York’s model is not a novel concept. Contact tracers were a major component of the national fight against syphilis in the 1930s. According to the city’s contact tracing website, a similar disease tracking system was used to fight tuberculosis outbreaks that occurred from the 1970s up until 1992. It also helped contain the 2019 measles incidence in NYC, the largest outbreak of the disease in almost three decades.

As more states launch their own contact tracing programs, it’s critical that they look at what’s worked in the past, and what appears to be working now. That means relying on people—not programming.

Of course, it was always more difficult to implement a national contact tracing system in the U.S. than say, South Korea, where the government has been monitoring citizens’ GPS and credit card usage to publish the travel routes of those who test positive. Senior advisor Jared Kushner, who was appointed by the president to oversee a “supply chain task force,” briefly considered creating such a surveillance system, but backed down after Democratic lawmakers pushed back with privacy concerns.

Still, Big Tech joined the national contact tracing conversation on April 10, when Apple and Google jointly announced plans to develop what they call Exposure Notification Software, which was marketed as a tool that individual states can use to develop their own apps. Apps using the software rely on Bluetooth-generated random identification numbers, which alert people if they’ve come into contact with other app users who record themselves as testing positive. States that’ve signed on for the software see anonymity as a benefit because it protects user privacy above all else.

But while that may appeal to some lawmakers, it’s not entirely advantageous. Positive cases reported by this technology are not sent to any public health agencies because of the software’s decentralized data storage. This means that any states hoping to maximize user privacy by using this software won’t be able to assist the human contact tracers collecting that data and working on the ground. For that reason, some states have developed their own software. Utah’s Healthy Together app assists the 1,200 contact tracers the state hired by helping tracers get in touch with people who have possibly been exposed.

The problem is that apps can only work if people actually use them. Software does nothing to help the 18 percent of Americans who do not have smartphones, who are overwhelmingly poor or elderly—and who are already more at-risk from COVID-19. Even still, only half of the 82 percent of Americans who do own smartphones reported that they “probably or definitely would not” use contact tracing apps due to privacy and security concerns.

These concerns are valid. Some apps have already been called out for questionable data-sharing practices. In April, app security firm Jumbo Privacy alleged that North Dakota’s Care19 app shared location data with Foursquare, unbeknownst to its users.

In contrast, New York Governor Andrew Cuomo has initiated one of the largest contact tracing recruitment operations in the country. New York’s program is hiring up to 17,000 contact tracers across the state. In NYC, half of the initial hires live in neighborhoods hit especially hard by the pandemic, meaning that these communities have tracers embedded within them. Cuomo’s state-wide program is also partnering with New Jersey and Connecticut to expand the program throughout the region. “It’s best to do this tracing on a tri-state area because that’s how the virus works. It doesn’t stop at jurisdictional boundaries,” said Cuomo during an April 22 press briefing.

New York’s plan may be well-funded and well-resourced, but it isn’t wrinkle-free. Just like polling and other phone-based work, contact tracing relies entirely on people’s willingness to engage with strangers. People across the political spectrum don’t want to do that—making the job of a contact tracer all the more difficult.

Even with these difficulties, however, New York’s program has managed to successfully track down positive cases by relying on tracers who often live in the same neighborhoods they’re working in. At the same time, it has come with an additional economic benefit. The economic fallout of the pandemic has been dramatic. The 17,000 hired contact tracers do not compensate for the 2 million people in New York who have filed for unemployment since April, but it does offer some of them with much-needed full time jobs that can help pay their bills and fight the virus.

With Donald Trump as president, Americans cannot count on an integrated national contact tracing initiative. It’s up to the states to take charge. If they want to keep their economies open without facilitating a huge surge in infections, they will have to trace cases the right way.

It’s impossible to predict which state’s program will ultimately be the most successful, but past and current efforts show that New York is leading the country in effective, person-led contact tracing. The logic is simple: Why spend millions of dollars on an app that few people will use, when you can hire and train people who desperately need jobs to do the work more effectively?

For contact tracing to be a national success, states need to make sure they’re hiring an adequate number of workers—meaning it would help if more states adopted New York’s approach.

According to former director of Medicare and Medicaid Andy Slavitt and former Food and Drug Administration chief Scott Gottlieb, the national contact tracing workforce needs 180,000 more tracers across the country, and a $12 billion budget. The disparity among states’ public health resources is evident in the sparsity of contact tracers in some regions: Mississippi, for instance, has more than 18,000 confirmed cases, but only had 250 contact tracers employed as of mid-June.

The nationwide reluctance and inability to use contact tracing apps signals that they won’t be the public health hero Google and Apple would like them to be. But if all states turn to hiring an adequate number of contact tracers, they can more successfully reduce the spread of the virus until a vaccine is ready. Otherwise, we may just keep suffering from the same level of dysfunction and disarray.

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Ellie Vance

Ellie Vance is an editorial intern at the Washington Monthly.