Coronavirus Magical Thinking, US Style: Contact Tracing Versus Masks
Since the US is a federal system with an Administration that refused to take coronavirus seriously early enough, and now seems determined to validate its original decision by doubling down on it, it is a bit simplistic to speak of a “coronavirus response,” since cities and states have been taking the lead and they’ve gone down different paths.
Nevertheless, due to the decision by many governments, particularly in the South, to start relaxing restrictions, I’m coming across way too many rationalizations. And one of them is that officials can make things safe enough with approaches like contact tracing. Mind you, as you will see, the point is that contact tracing, or any information gathering, practiced on an insufficient scale and without programs to take disease containment steps using that data, is at best misguided, and at worst, intended to build false confidence.
Put it another way: the enthusiasm for a gee-whiz, tech based approach with no real world back end doesn’t merely reflect a lack of operational capacity, a key point Lambert made yesterday. It reflects a grave decline in basic problem-solving and planning skills, as in how do you get from A to B. And there bizarrely is limited interest in the one thing that could be done easily and cheaply, which is getting tough about mask-wearing.
On top of that, one measure that really could make a difference, mandatory mask wearing, isn’t required many places, and even in those locales, not in a sufficiently bloody-minded manner.
The first biggie is that it had to be this way. No, it didn’t. Note that Slovenia, which borders Italy, has the disease pretty well contained. From EndCoronavirus.org:
Countries beating Covid-19
Even countries that had very bad outbreaks like Italy and Iran have considerably reduced infection levels:
Countries that are nearly there
Countries that need to Do Something
The US is not in good company. Note how Singapore is now sitting at the “bad performance” table due to outbreaks among its migrant worker community…which is now quarantined in housing that makes social distancing pretty much impossible.
It turns out that big contagion vector was air travel. Epidemiologist Ignacio had this intuition a few weeks ago. Via e-mail:
Prompted by discussions on epidemics management (or lack thereoff) and cummulative casualties in various countries I have compared the “air connectivity” of various European countries with cummulative casualties with a lag corresponding to the clinical lag between contagions and casualties. Air connectivity is measured by daily flight departures for each country the week ending the 13th of March. And cummulative casualties up to April 7th.
When I plot both variables using logarithmic scale for both, I obtain a fine visual correlation:
The correlation coef. between both variables is about 0,84 though I have not checked if the distribution of both is normal.
Reader David sent along this pre-print (as in not-yet-peer-reviewed) article at MedRxiv that comes to similar conclusions. Its abstract:
The pandemic state of COVID-19 caused by the SARS CoV-2 put the world in quarantine, led to hundreds of thousands of deaths and is causing an unprecedented economic crisis. However, COVID-19 is spreading in different rates at different countries. Here, we tested the effect of three classes of predictors, i.e., socioeconomic, climatic and transport, on the rate of daily increase of COVID-19. We found that global connections, represented by countries importance in the global air transportation network, is the main explanation for the growth rate of COVID-19 in different countries. Climate, geographic distance and socioeconomics had a milder effect in this big picture analysis. Geographic distance and climate were significant barriers in the past but were surpassed by the human engine that allowed us to colonize most of our planet land surface. Our results indicate that the current claims that the growth rate of COVID-19 may be lower in warmer and humid tropical countries should be taken very carefully, at risk to disturb well-established and effective policy of social isolation that may help to avoid higher mortality rates due to the collapse of national health systems.
I know a cool network chart does not make the authors right, but nevertheless:
As PlutoniumKun added:
I still scratch my head at the insistence of WHO (and other authorities) at the beginning of this that airline travel was not a particular problem. I scanned the studies they used to support this conclusion and none seemed very convincing to me. I think its hard to avoid the conclusion that WHO simply shied away from the implications. The thing is, a lot of public authorities were relying on WHO’s recommendations on this – it took a brave politician/official to shut down airports in the face of this.
You can go back to 1895 and the Russian flu to see this – it was clearly (and rapidly) spread across the northern hemisphere along the main railway routes.
Additional support for the airport thesis comes from the fact that New York was the main source of coronavirus for the US.
Back to the main plot: what should the US (and other pretty badly afflicted countries) do, given where they are now?
The Contact Tracing Delusion
The depressing thing about the contact tracing plans in the US is that they demonstrate how incompetent we’ve become as a people. We were able to send a man to the moon 50 years ago. Now all we seem able to do is build apps when they won’t solve anything.
Way too late for contract tracing to work. Joseph Norman, Yaneer Bar-Yam, and Nassim Nicholas Taleb pointed out in a January paper that contact tracing was ineffective once a disease reached pandemic scale:
Global connectivity is at an all-time high, with China one of the most globally connected societies. Fundamentally, viral contagion events depend on the interaction of agents in physical space, and with the forward-looking uncertainty that novel outbreaks necessarily carry, reducing connectivity temporarily to slow flows of potentially contagious individuals is the only approach that is robust against misestimations in the properties of a virus or other pathogen….
Standard individual-scale policy approaches such as isolation, contact tracing and monitoring are rapidly (computationally) overwhelmed in the face of mass infection, and thus also cannot be relied upon to stop a pandemic. Multiscale population approaches including drastically pruning contact networks using collective boundaries and social behavior change, and community self-monitoring, are essential.
Together, these observations lead to the necessity of a precautionary approach to current and potential pandemic outbreaks that must include constraining mobility patterns in the early stages of an outbreak, especially when little is known about the true parameters of the pathogen.
In keeping, China tamed its outbreak not with contact tracing but with a combination of aggressive testing for fever and confinement of anyone exhibiting one, required mask-wearing, and social distancing. Interestingly, other reports indicated that Beijing, and one assumes other major cities outside Hubei, did not have all non-essential businesses closed. About 1/3 of the restaurants and bars were open, seating customers, but only well spaced out. From an Agence France-Presse account:
Every time I enter a building nowadays, I say a little silent prayer before a little plastic gun is pointed at my head. After all, the contraption literally holds the key to whether I get in or not…
The little plastic gun is an electric thermometer and it has become ubiquitous in China and in the battle against the virus and the COVID-19 disease that it causes. A fever is one of the first symptoms and so the right temperature is essential in entering your office building, the supermarket, restaurant, public transport or your apartment building….
The taking of temperature has become a daily ritual for everyone living in the Chinese capital…
At the office building housing the AFP bureau in Beijing, the hunt for infectees does not end with the temperature taking. First I have to produce a brand new “entry and exit” card that building management made for this epidemic and that allows people to come and go from the 31-story structure. Then I walk in front of an infrared camera that stands ready to catch the fevers the thermometer may have missed….
In the elevator, there is a box of tissues, so that you don’t have to press the buttons with your bare hands. And at our office, the keypad where I have to press the entry code is covered in plastic (easier to disinfect and replace)….
A sign on our door reminds us that there can be no more than 12 people in the bureau at once (half of our staff normally) and security guards check in occasionally to make sure we’re complying. “You have to wear a mask, even when you’re working,” one of them says during one such inspection…
Outside, wearing a mask has become mandatory pretty much everywhere, even in the parks…
So the approach in China, which worked pretty well given the scale of the outbreak, was the use of temperature as a real-time test, with immediate quarantining, social distancing, and mandated mask-wearning. Notice the manpower was devoted to testing (the many temperature-scanners) and enforcement (the AFP story described several policeman coming into a restaurant, screaming it was too full, and forcing everyone to leave).
What About South Korea?
Yes, what about South Korea? On the one hand, Seoul, with a population bigger than that of New York City, has had two coronavirus deaths. Two. Even if they are off by a factor of 100, it’s still two orders of magnitude less than the 20,000 and counting deaths in the five boroughs.
And the country is so fixated on coronavirus that the discovery of a mere 34 new cases led the government to shut all bars and nightclubs until they tracked down all the people who’d been at the venues. That was an estimated 7,200. Numbers like that are manageable, but look at the draconian additional steps the officialdom is taking to make sure it doesn’t propagate beyond that.
The other central measure in South Korea is widespread, no-wait, fast turnaround testing. And the techs are in full hazmat attire.
Lambert featured this tweetstorm yesterday. I suggest you read it if you didn’t have time:
As an American currently in South Korea, it’s very interesting to me the stark contrast of how different the two countries’ response to coronavirus is. I don’t think most Americans fully understand the lengths that South Korea has undergone, so I’ll try my best to explain.
— Michael Kim (@michaelvkim) May 9, 2020
In the replies, there were a lot of comments about “No way would I give up my freedom like that” (ahem, the airport in Seoul was full of soldiers in combat gear carrying machine guns even before coronavirus) but some got the tradeoff:
yup. i live in Korea. people never stopped going clubbing, to bars or restaurants. we don’t get fined for non-essential travel—as long as we’re not breaking quarantine.
— Erockfor (@erockfor) May 11, 2020
Contact Tracing US Style: Potemkin Public Health
Let’s start with the basics. For contact tracing to be effective, you need to identify a decently high percentage of the infected and then get them to quarantine and be treated as needed.
The big and obvious fail in the US is no one is willing to forcibly quarantine people. And even if it were ordered, how would compliance be enforced? With ankle bracelets? Anything else is subject to cheating, and plenty of Americans would cheat.
Plus many individuals are in households where they can’t isolate. The sick person needs his own bathroom, at a minimum. So absent that, the entire household needs to be quarantined too.
On top of that, testing needs to be sufficiently widespread to catch a high percentage of the infected before or very shortly after they become symptomatic, and identify who might have been nearby during the high viral load shedding period. Given that this extends over several days, that’s not necessarily easy. Add to that that only about 80% of Americans own smartphones, and some don’t carry them all the time.
So when I read about the state plans to start contract tracing, it sounds like a 21st century version of Keynes’ proposal to stimulate demand by hiring people to dig ditches and fill them back up. From The Hill:
State governments are building armies of contact tracers in a new phase of the battle against the coronavirus pandemic, returning to a fundamental practice in public health that can at once wrestle the virus under control and put hundreds of thousands of newly jobless people back to work.
California is already conducting contact tracing in 22 counties, and it eventually plans to field a force of 10,000 state employees, who will be given basic training by University of California health experts.
Massachusetts and Ohio have partnered with Partners in Health, a global health nonprofit originally established to support programs in Haiti, to field teams of contact tracers. Maryland will partner with the University of Chicago and NORC, formerly the National Opinion Research Center, to quadruple its contact tracing capacity.
Washington, West Virginia, Iowa, North Dakota and Rhode Island are using their National Guards to trace contacts of those who have been infected with the coronavirus….
If those contacts then come down with the virus, they can be quickly isolated so they do not spread it further. They can also be treated, making it less likely they develop the most severe symptoms.
“They can be quickly isolated.” This is the DC version of the economist’s “Assume a can opener”. How, exactly? Will they be thrown in the back of an ambulance and hauled away to a medical lockdown? About 41% of American adults have kids under 18 in the household. How can they be “quickly isolated” when childcare is an issue? Pray tell, where is the model statue to go about doing this? And who bears the costs? Or is the hope that a South Korea-style $10,000 per infraction fine will do the trick? In reality, that won’t phase Hamptons or Silicon Valley denizens.
On top of that, the reverse-transcription polymerase chain reaction test, used to test if people currently have coronavirus suffers from a high false negative rate, estimated at anywhere from 15% to 30% (usually due to faulty administration). And they apparently still do not know what the false positive rate is in the field, which could make any effort to quarantine someone who was not symptomatic against their will subject to legal challenge.
Even The Hill acknowledges some problems well down into the article:
But contact tracing can work only if the number of new cases the United States confirms every day begins to bend down to a manageable number. The number of cases confirmed in the United States has grown by at least 25,000 on all but two of the first eight days of May.
And tracing will become an effective tool only when those who are conducting the tracing have the ability to test people broadly and to get the results of those tests back quickly. The Food and Drug Administration said Friday it had approved both the first diagnostic test that could be conducted using home-collected saliva samples and the first antigen test, a type of test that delivers results much faster than others on the market.
The lack of available tests at the earliest stages of the coronavirus outbreak has hidden the true extent of the virus’s spread around the United States. While some countries have the capacity to test huge percentages of their population on a given day, the United States is still testing only about 250,000 people per day, a level far short of the capacity necessary to conduct widespread contact tracing.
Why Are We Ignoring Masks?
Getting people to mask up is way easier and faster, although it doesn’t give people in the Beltway the opportunity to strut and take credit. And by “mask” we don’t mean a surgical mask; a bandit-style cloth bandana will cover the nose and mouth and does an even better job of preventing face touching.
A new study confirms our priors. From Vanity Fair:
But a compelling new study and computer model provide fresh evidence for a simple solution to help us emerge from this nightmarish lockdown. The formula? Always social distance in public and, most importantly, wear a mask.
The day before yesterday, 21 people died of COVID-19 in Japan. In the United States, 2,129 died. Comparing overall death rates for the two countries offers an even starker point of comparison with total U.S. deaths now at a staggering 76,032 and Japan’s fatalities at 577. Japan’s population is about 38% of the U.S., but even adjusting for population, the Japanese death rate is a mere 2% of America’s.
This comes despite Japan having no lockdown, still-active subways, and many businesses that have remained open—reportedly including karaoke bars, although Japanese citizens and industries are practicing social distancing where they can. Nor have the Japanese broadly embraced contact tracing, a practice by which health authorities identify someone who has been infected and then attempt to identify everyone that person might have interacted with—and potentially infected. So how does Japan do it?
“One reason is that nearly everyone there is wearing a mask,” said De Kai, an American computer scientist with joint appointments at UC Berkeley’s International Computer Science Institute and at the Hong Kong University of Science and Technology.
Now the Japanese are also clean freaks, but the flip side is despite riding on sardine-packed subways in Tokyo, they aren’t big on hand-shaking or backslapping. They tend to maintain distance when they can. Nevertheless, masks look to be the big explanatory variable.
In the US, the state-level mask-wearing laws are wimpy. This CNN article lists only Connecticut, Hawaii, Maryland, New Jersey, New York, Pennsylvania, and Rhode Island.
New York’s is the toughest, yet you can still drive a truck through the loophole:
All residents over age 2 must wear masks or face coverings when they’re in public and social distancing isn’t possible (though maintaining at least six feet of distance is always preferred).
So if you go to a store at off hours and give other customers a berth, or hop into a cab and stay on the right side of the back seat, you are complying
By contrast, Rhode Island’s covers only employees of essential businesses.
So what is America’s excuse? Of all places, Birmingham, Alabama is doing a better job, As they are unlocking in phases, they have implemented a serious mask law, passed at a city council meeting where all the council members were wearing masks and well spread out in their chambers:
Masks or face coverings are required in all public places in Birmingham effective May 1.
The Birmingham City Council on Tuesday morning approved the ordinance requiring face coverings for all 2 and older….
The ordinance defines a mask as “A device to cover the nose and mouth of a person to impede the spread of saliva or other fluids during speaking, coughing, sneezing or other intentional or involuntary action.” It doesn’t require the masks be medical-grade, just that they cover the wearer’s nose and mouth.
The masks must be worn in all public places, which the ordinance defines as anywhere outside the person’s vehicle or home…
Business owners will also be required to make employees wear masks while at work. However, the ordinance says “this shall not be interpreted as requiring businesses to provide face coverings or masks to employees.”
Failure to comply with this ordinance is punishable by a fine of up to $500 and/or up to 30 days in the municipal jail. Woodfin says a violation of the ordinance should be treated like a curfew violation. Violators will be allowed to either pay a fine or appear in court.
That means churches too. Only exercising outdoors is exempt.
And not only has the city set meaningful fines, it is collecting them. I overheard a woman who is in a high risk category and therefore very grateful for the law, tell a cashier at the local drugstore that the police were ticketing scofflaws at the Lowes (a home supply store) the very first weekend.
Now this situation is still not ideal. The law applies only in Birmingham proper, not even in all of Jefferson County, so in my little suburb, masklessness is still the norm.
Another important part of the Birmingham move is that city officials are now always wearing masks. A big impediment to getting Americans to take mask-wearing seriously is the lack of modeling. If Democrats really wanted to get Trump’s guff as well as make a point, why are Governors Newsom, Cuomo, Inslee, and all their staffs masked up, particularly for photo ops? Why aren’t Pelosi, Schumer, and all their fellow party officials sporting face wear, particularly when they get the opportunity to stand next to Republicans?
For instance, vlade says in the Czech Republic, the government mandated mask-wearing and social distancing and made a point of leading by example, which included having TV hosts wear masks. China was also conscious about the need to walk the talk, although it was tripping over its feet in the beginning From Agence France-Presse:
Take the first presser organized by the health ministry three days after Wuhan and its 11 million residents was placed in quarantine. Before the start, journalists wearing face masks were ordered to take them off so as not to appear on camera with them.
But “when the presser started the de-masked journalists listened as an official emphasized the importance of building a ‘face mask culture’ to prevent the virus from spreading,” Matthew Knight, our video journalist, told me.
Needless to say, it didn’t take long for reporters to be told to wear masks and to be seated a bit apart from each other too.
By contrast, here the press has if anything been playing up mask defiance, not just in covering shootings of store personnel by mask refusniks, but in the spin. The press has been dwelling on the horror, playing up the fear factor. That has the effect of discouraging other businesses from enforcing mask policies. The media should be clear about the cowardice as well as criminality of these shootings, by showing law enforcement officials describing the sentences if the suspects are tried and found guilty, and focus on the damage by presenting the victims’ families.
I wish I could be more hopeful. On the one hand, it’s great news that have a simple remedy that could get large swathes of the economy back to normal. On the other, the US seems so unable to get out of our own underwear that it’s not clear we are wiling to do something simple that works because no opportunities for corporate grift can be found. Can’t let those Gilead stockholders down, now can we?