S1: For a century, doctors fighting infectious diseases have relied on a simple idea. When you find a positive case, find the people that the patient might have exposed. This is called contact tracing.
S2: Contact tracing is hard enough with, say, HIV, where someone who tests positive might know the names and phone numbers of their recent sexual partners. But with Corona virus, it’s a different story. The disease is airborne, contagious, and it can spread for days before a patient begins to show symptoms, making it hard to figure out who might have been exposed. That’s what put the world on lockdown.
S1: Now, doctors say that contact tracing, along with widespread rapid testing and social distancing, is our only way out.
S2: In the U.S., states and companies are trying to meet that need. Massachusetts has hired a thousand people to start a contact tracing program. And Google and Apple have collaborated on an app that uses Bluetooth to keep track of who you run into all day, which for the average New Yorker, might be as many as seventy five people, not including contacts on public transit. Today on the show, we’re going to hear from a country where covered 19 tracing has worked in an American city that’s about to try it. I’m Henry Goodbar, filling in for Lizzie O’Leary. And this is what next TBD. Stay with us.
S3: So what does it look like to spend a day in Seoul right now? Honestly, it’s business as usual. This is Rafael Rasheed. He’s a journalist in Seoul.
S4: It’s like any other day, especially at the moment. The worst is over.
S5: And right now, I can do anything I want.
S6: South Korea didn’t flatten the curve. They never had any curve at all. On Wednesday, they even had an election with record turnout.
S7: Shops are open. Coffee shops are open. Restaurants are open. Yesterday was a public holiday because we had voting. But everyone was in the streets holding hands, going to coffee shops. The weather was nice. And it said, buying time. Yeah. It’s as if nothing had happened. And I kind of feel a bit guilty because I can see, you know, friends and family abroad is a completely different story.
S8: Are you posting a posting on your answer? You know, here I am in the past.
S7: A movie. I do feel a bit bad posting these these like normal life stories because I know it’s not the case for everyone else around the world. But definitely we’ve seen a lot less cases in Korea.
S4: I think now we’re hovering at about 20 to 25 new cases a day. So it’s very, very minimal.
S1: This is minimal because of South Korea’s sweeping contact tracing program, which the country developed as a response to another viral outbreak in 2015. Interviews, investigations, local alerts. Everything was in place when Colbert arrived and participation is mandatory.
S9: The South Korean government has been very good at tracking and tracing down all of the confirmed cases of coronavirus in the country. At the beginning, you know, once someone was confirmed and they they got their positive results. The government would ask them questions. Where were you? What time? Where did you go?
S8: What was your route like being like being interviewed by the FBI or something like that?
S9: Yeah, literally interrogated. But the problem is, I mean, some people were very good at it, but at giving answers. But some people just forgot where they were for the past few days. And I think some people actually refused to say where they were. So when we have a pandemic, the government is allowed to look into your private records, your credit card records, your G.P.S. tracking. So they’re allowed to get a lot of information from you. And actually, it facilitates the process of finding out where you are. So what the government does with this information is they copilots and then they make what they call an emergency broadcast. So, for example, if someone in your area comes out as a positive coronavirus case, then everyone in that area will receive a text message on their phone saying, be careful. There was a confirmed case in your area and you can’t really opt out of these messages.
S10: They just come on your phone and they make a massive siren and everyone’s phone. If you’re in a coffee shop, everyone’s phone goes off at the same time to say alert. They won’t tell you their name or address, but it will tell you their gender, their age. They might even tell you what kind of job they do and it will tell you what route they took. So they went to this movie theater. They went to this coffee shop at this time. They took this bus. They took this subway. It will give you all the information and then it will usually give you a link and say, if you want more information, please log on to this Web site and it will lead you to a Web site that will give you even more information.
S8: There was a point when South Korea was confirming hundreds of new cases a day. If you were in a big city, this must have been quite frenetic. You must have been getting alerts all the time saying case here, a case there.
S9: Absolutely. We were getting maybe 20 alerts a day, maybe 30. It really depends if you know what what area you’re in. And now it’s getting better because we’ve got less cases. But definitely a month ago or six weeks ago, it was. It was a bit overwhelming.
S8: Right. And so you’re saying that when you were in a public space, you would get them all the time. And it’s weird because it seems like on the one hand, it would make people nervous. On the other hand, it’s referring to something that might have happened three or four days in the past. Right. So then then it’s up to you to trace your trajectory and figure out if you might have been in the same place at the same time.
S9: Yeah, absolutely. I mean, you can just go back in time yourself and ask yourself, was I at this place at this time? And if so, how long was I in that place? And you can determine whether you potentially were at risk or not.
S11: Right. I suppose that your location is only being revealed by the government if you test positive. So it I’m wondering what it’s like for people who do test positive. Is there a stigma associated with that? Do they feel vulnerable having all their locations broadcast like this?
S4: Yeah, I mean, here’s the thing. You know, it just says Mr. Kim, 58, who lives in this area.
S12: And, you know, there are there are hundreds, if not thousands of people with the same surname.
S11: In any given area, I’m sure they release your name.
S4: Yeah, they will release in Korea.
S13: Names are usually three syllables, your your surname and your full name. It’s a combination of three syllables. So your first syllable will be revealed. Like Kim and Kim and Pak.
S4: But the thing is, these names are so common in Korea, most people have the same surnames. So it’s very difficult to tell. I see if you if you are Korean because everyone is a Mr. Pak. Everyone is a Mr. Kim. If it were you. Yeah, exactly. So that is kind of in a way it’s okay if you’re Korean, although if you live in a very small village, maybe it’s very easy to guess who it is. If you’re a foreigner, it’s interesting because they released the nationality, which I’m not too sure why they need to give the nationality.
S13: So for example, if it were me, it would be Rafah dot dot.
S4: So I wouldn’t give my full name, but give the beginning of my name. It would give my age, I think would give my profession. And I’d give my area. I give my. Yeah. My nationality set. Not many people can fit that criteria. This property. I’m probably the only one. And people would probably guess immediately that it’s me.
S3: How do you think people in South Korea feel about. Giving up their privacy in this situation.
S12: Honestly, I dont think people think much of it. I mean, yeah, they do understand. It is a breach of privacy and in theory a breach of your human rights. But many South Koreans believe that safety comes above your privacy.
S1: I suppose it’s also partly that they have faith in this system. It’s not just that. It’s not just that the system works on a technical level, but that people feel confident about going about their normal lives. Even if there is a surge in cases, they they they assume the government has it under control.
S4: Yeah. Interestingly, it wasn’t necessarily always the case at the beginning of the outbreak.
S13: There was a lot of criticism, especially from the opposition party who criticized the government and the president for not closing the borders from day one.
S12: But things changed when it turned out to be the opposite abroad, when there were thousands of cases abroad in the US and the UK, Italy, Spain. When Koreans realized that actually the government’s been doing a pretty good job in this country, considering how bad it is in other countries, then the narrative changed and then approval ratings for the president and the ruling party just shot up.
S7: And and that’s why I think we’ve seen extremely high results and performance yesterday in the National Assembly elections, which had a record turnout and an absolute landslide victory for the ruling party.
S14: In America, of course, things are different.
S15: Disorganized, thousands of people are dying every day.
S14: And yet with pressure building to get people back to work. States are starting to plan for what comes next. And so is Dr. Michael Reed. He worked on contact tracing with tuberculosis in sub-Saharan Africa.
S16: Now he’s trying to start something similar in San Francisco. It was one of the first places in the US to register community transmission of Cauvin 19, but it has all but flattened the curve.
S17: Well, first of all, I think there’s a recognition that in order to do effective contact tracing, we needed to scale the workforce beyond the department, public health, the all of their professionals are tapped out doing important work. And we need more boots on the ground, so to speak.
S16: So Dr. Reed is helping out his university. UCSF plans to add scores of people in support of the city’s public health department. Dr. Reed is coordinating this effort.
S18: One of the first things that the Department of Public Health does here in San Francisco is that they mobilize a team of disease case investigators sounds like a very legal term. But as these folks are trained professionals who will reach out to each individual suffering from KOVR 19 and first of all, checking on their welfare, how are they doing? Are they medically stable? And then try and understand when do they fall ill and what kinds of activities did they participate in after they fell ill in the process of that interview or investigation? The disease case investigator will enumerate all of the contacts that that individual came into contact with during that period of time when they were infectious, generating a list of contacts at this point.
S16: Once the initial interview is done, the Doctor Reed’s team gets involved. In short, they start making calls.
S19: And our role is, first of all, to highlight or educate those individuals. Hey, we believe you’ve come into contact with somebody kohver 19.
S18: And because of that, you’re rescue yourself of developing symptoms of Kovac, 19. And we would like to ensure that you protect yourself from infection by staying home, by quarantining a home for 14 days. And then we ask these folks, are you able to safely do that and what resources do you need in order to safely self-quarantine?
S6: Sounds like South Korea, doesn’t it? Well, there’s two big differences. First, American doctors can’t force covered patients to cooperate. Second, San Francisco is just one city to make contact tracing work. You need to do it at scale.
S18: We’re guesstimating that in the first instance here in San Francisco, we need between 100 and 150 people that can do contact tracing if we’re ever to pull back from shelter-in-place. What does the US need? I mean, the numbers are sort of mind-boggling, but people are estimating we need between 100 and 300 thousand people that can be doing contact tracing. If we as a nation are able to effectively hold the epidemic at bay.
S11: How do you think about the number of people required to do contact tracing in proportion to new cases? So how many traister’s per patient?
S17: It’s it’s just simple. Back of the envelope math right now. You know, we’re estimating that the each case is in close contact with between 3 and 5 people. I think that number will probably go up as as people go back to some degree of normality. But we’re mobilizing a team that reflects the fivefold increase on the number of cases so that we’re able to reach out to those cases. And then we sort of back into the number. If we’re thinking that there are going to be five contacts per case, if it takes 20 minutes to get on the phone with each of those contacts, that three an hour, how many can you do in a day and therefore, how many contact traces do you need to do that? And that’s how we sort of came up with that number in the first instance.
S11: It strikes me that the potential number of contacts is three to five is based on the current shelter in place, status quo. I have seen studies that when a city is functioning normally that your average urbanite might interact with 60 to 70 people now.
S20: Yeah. I mean, there’s there’s modeling out the mathematical modelling suggesting, you know, much higher numbers. And if you look at the murres outbreak, Middle Eastern respiratory virus, the you know, the average number of contacts is closer to 30.
S17: So I’m absolutely aware that the figure that I’m proposing right now is modest and hence why we need to mobilize the workforce now so that we can anticipate an increase in the number as we return to normal at some point in the near future. Right.
S11: Even so, it seems to me that this this system is predicated on putting more emphasis on a certain type of high touch contact, which is to say a roommate or an employee, a colleague with whom you. You work in close proximity rather than, say, somebody you passed on the sidewalk on your way to work. Does that reflect your sense as an epidemiologist about where the infections are most likely to occur?
S20: Yeah, I think so. I mean, the established wisdom is that the greatest risk of transmission is, is if you spend more than 10 minutes in close proximity, less than six feet from an individual who symptomatic. And so certainly, you know, people that will automatically fall into that criteria are a roommate’s household contacts and maybe your close contacts at work, depending on what kind of work you do. Are we gonna be able to capture information on everybody? You know, the man that you sit next to on the bar stool or the individual in the line for the grocery store? No.
S11: In places where people are now taking this outbreak very seriously in their daily lives, like in shop in the Chicago neighborhood where I live. You walk down the sidewalk and you’re wearing a mask and you see someone else and they’re wearing a mask. And each party will one party will often leave the sidewalk and walk in the street to avoid walking within 10 feet of each other. And that has been the message we’ve gotten from public health officials that you should stay six feet away from people at all times. But it sounds like if the program you’re proposing is to have is to be effective in any way, it sort of relies on the assumption that actually walking by someone on the sidewalk is a pretty low risk event.
S21: I think it is a low risk event. What mask wearing and social distancing are doing are like recognizing that we don’t have better tools in our armamentarium. Right. So even though it’s a very crude intervention, it’s the best that we have. And maybe contact tracing adds a degree of precision that those other interventions on able to offer. But honestly, we need all of them because we dont have a vaccine. We don’t have an effective therapeutic intervention. And so all of these different things that are relatively crude and insensitive in terms of reducing transmission are as good as we’ve got.
S20: And I think this is where there may be a role for other forms of technology to enhance the precision of our contact tracing work.
S16: That mean you want to ask Dr. Reid about that? Apple Google tracing app. If a user later tested positive for Cauvin 19, the absolute truth tracing could tell you where and when you came across them.
S19: I think it has a small role and I don’t want to diminish the value of it for end users who are motivated, who want to have this information. But if you look at a similar application that was developed in Singapore, the Trace Together application, which was also voluntary, you know, only about 15 percent of individuals used it. So I think that’s one reflection. The other reflection is that the kind of app that’s being proposed really relies on the individual acting all of their own volition to to make a change in their lifestyle. And that’s never going to replace the important role of of a Department of Public Health that can to reach out to you and say, hey, we know you’ve been infected, you need to do these things. And actually we require you to do that as part of your your social responsibility within our city.
S22: And I worry that those end user applications aren’t ever going to fulfill that or offer that message of responsibility at a population level.
S16: Whether it’s an app or an investigator retracing your steps, this whole idea only works in an environment where the disease is contained in us right now, we’re just not ready.
S17: I think there are many cities and counties across the US that have essentially thrown in the towel and contact tracing right now. They just can’t do it because that the burden of disease and their public health infrastructure is already overwhelmed and their priority is to figure out where can we get enough PPE from? Do we have enough ICU beds and can we accommodate all the people that need ventilators? I think hopefully inevitably almost that surge will end. And then, you know, those communities will come down the other side of the curve. They’ll have to regroup and then figure out before the next wave of infections. All we ready? Do we have case investigation and contact tracing capability? Are we able to test everybody? And can we offer those wraparound social services that seem to be really crucial if we’re going to support people through the epidemic?
S23: Well, Dr. Reed, thank you so much for talking with us. Yeah, you bet. My pleasure. Dr. Mike Reed is a professor of medicine at the University of California, San Francisco. Rafale Rashid is a freelance journalist based in Seoul. And that’s our show for today. I’m Henry Gabbar. What next? TBD is produced by Ethan Brooks and is part of the larger what next family. TBD is also part of Future Tense, a partnership of Slate, Arizona State University and New America. What next will be back on Monday. Thanks for listening and have a great weekend.