States, Experts Start Pursuing National Coronavirus Strategy Without White House Guidelines


But there is no evidence that the White House will pursue such a strategy.

Instead, the president and his senior advisers have focused almost exclusively on plans to reopen the U.S. economy by the end of the month, although they have not specified how they will do it without triggering a new epidemic. President Trump has focused particularly on the creation of a second coronavirus task force to tackle the economic ramifications of the virus.

Administration officials, speaking on condition of anonymity to describe internal deliberations, say the White House has made a deliberate political calculation that it would be better for Trump to place the burden on governors – rather than the federal government – to figure out how to move forward. in front of.

“It’s mind-boggling, in fact, the degree of disorganization,” said Tom Frieden, former director of the Centers for Disease Control and Prevention. The federal government has already squandered February and March, he noted, committing “epic failures” on test kits, ventilator supplies, protective equipment for health workers and conflicting communications from public health. The next failure is already on the way, said Frieden, because “we are not doing what we have to do in April”.

White House spokesman Judd Deere said on Thursday that “The president wants this economy to open up again so people can get back to work, but science will guide the timing of these decisions because its number one priority is to protect the security and well-being of the American people. ”

In recent days, dozens of leading voices have merged around the test-trace-quarantine framework, including former FDA commissioners for the Trump administrations and George W. Bush, Microsoft founder Bill Gates and experts. high-level students from Johns Hopkins, Columbia and Harvard universities.

On Wednesday, former President Barack Obama weighed in, Tweeter: “Social distancing curves the curve and relieves some pressure. … But to change current policies, the key will be a robust testing and monitoring system – something that we still have to put in place on a national scale. “

Friday, Apple and Google unveiled a joint effort on new tools that would use smartphones to facilitate contact tracking.

What is not clear is whether this new plan can succeed without the support of the federal government. Some states like Massachusetts and Utah are already trying to implement parts of it. In the absence of federal leadership – as happened last month with residence orders – other states could monitor and follow suit. But without substantial federal funding, state efforts will not go

In South Korea, Taiwan, China and Singapore, national governments have implemented variants of this basic strategy, allowing them to keep the virus under control even as they reopen parts of their economy and the society.

In America, the tests – although they are still terribly late – multiply. And households across the country have learned in the past month how to quarantine. But for the second pillar of the plan – the labor-intensive contact-finding work – local health services lack the necessary staff, money and training.

Experts and leaders in some states say fix weakness should be a priority and health services need to be bolstered quickly so they are ready to act in the coming weeks as infections spread nationwide begin to decrease. Johns Hopkins Center for Health Security and the Association of State and Territorial Health Officials – which represents state health services – estimate that 100,000 more contact tracers are needed in a report due to be released on Friday $ 3.6 billion in emergency funding for Congress.

The CDC is exploring ways to increase contact tracing capacity, director Robert Redfield said in an interview with NPR on Friday. But these efforts have not been reviewed by the White House, and the role of the disease control agency has been diminished in the administration’s pandemic response. “We are definitely in the middle of it all. It is premature for me to deploy it, ”said Redfield.

Technology, like the Apple-Google partnership, is also under development that could help this effort, but it comes with civil liberties issues that need to be resolved.

Unless states can aggressively detect and isolate the virus, experts say, there will be new epidemics and another series of disruptive home stay orders.

“Everyone is talking about hospital beds, ventilators, tests, tests, tests right now. Yes, these are important, but they are all responsive. You are dealing with the symptoms, not the virus itself, ”said Tolbert Nyenswah, who led one of the most successful contact tracing efforts in Africa during the Ebola epidemic from 2014 to 2016. “You will never beat a virus like this unless you advance it. America should not just flatten the curve, but take a step ahead. “

Create an army

Six years ago, Nyenswah saw an even more deadly disease, Ebola, cross his native country. The President of Liberia hired him to lead his response and Nyenswah immediately hired an army of surveillance officers to trace the “leather”. This involved going door to door to find anyone who had interacted with someone with a confirmed case of hemorrhagic disease and persuading them to stay inside, even providing food and services to make it happen. more likely.

The test itself is useless, Nyenswah said, because it only tells you who already has the virus. Likewise, tracing alone is useless if you do not place those you find in quarantine. But when all three are implemented, the chain of transmission can be broken.

Until a vaccine or treatment is developed, such non-pharmaceutical interventions are the only tools that countries can rely on – apart from locking up their cities.

In 2014, the army of 4,000 public health workers from Nyenswah used tracing to eradicate Ebola in Liberia in even more difficult circumstances. Many houses did not have telephone lines, much less house numbers, street names or postal codes to navigate.

“We did not have the sophisticated systems you have in the United States,” said Nyenswah. “Many of the people we dealt with were not even literate, but we managed to win. What it tells you is that it can work. “

But to expand this to a country as large as the United States will require a huge dose of money, leadership and political will.

Nyenswah, who now lives in the United States and teaches to Johns Hopkins, watched the disjointed reaction of the United States on television with growing alarm.

“You cannot have leaders who contradict each other every day. You cannot have states waiting for the federal government to act and for the government to tell the states to figure it out for themselves, ”he said. You need a plan. ”

Intimidating Mathematics of Transmission

When the first case of Vermont coronavirus was detected last month, it took two health workers a day to find 13 people who had come into contact with this single patient. They quarantined them and started monitoring the symptoms. No one else got sick.

“It was a tidy bow,” recalls Daniel Daltry, one of the two health workers who did the work.

Within days, new cases “arrived like dominoes,” Daltry said. At the end of March, his team ran on a single day to find the contacts of 12 patients, when an additional 30 cases landed on their desks.

He did the math: if each of these 30 patients was in contact with even three people, that meant 90 people his team would have to locate and quarantine. In other words, impossible.

This is the disheartening calculation faced by the country’s health services. Since 2008, health agencies in cities and counties have lost almost a quarter of their staff. Decades of budget cuts have prevented them from mounting such a response. State health departments have had to fire thousands of others – an unintended consequence of federal officials delaying tax returns until July without notifying states. These federal deposits generate state revenues.

In Wuhan, a city of 11 million, the Chinese had 9,000 health workers doing contact tracing, said Frieden, the former director of the CDC. He estimates that in the United States, authorities would need approximately one contact tracer for four cases.

Such large-scale tracing at the national level might be possible if federal funding and guidance supported counties while social distancing lowered the number of cases.

“We could use a stronger voice from the White House to mobilize this nation,” said Washington Governor Jay Inslee (D) on Thursday. “In the second wave, we need to have tests, a resource base, and a contact search base that is so much more advanced than it is today. It’s a huge challenge. ”

Not waiting to act

In the absence of a federal directive, Massachusetts unveiled a plan last week to begin building an army of contact tracing.

Governor Charlie Baker (R) has joined a Boston-based international nonprofit group that is carrying out this type of public health campaign against communicable diseases, including tuberculosis in Africa and HIV and cholera in Haiti. The non-profit health partners quickly developed a plan to hire and train 1,000 contact tracers. Working from home, making 10 to 12 calls a day, they could cover up to 20,000 patients a day.

The group pays new hires roughly the same salary as the enumerators, about $ 20 an hour. On Tuesday – just four days after the initial announcement – the group had received 7,000 applicants and hired 150.

“People want to help. They are tired of sitting at home and waiting to get infected, “said KJ Seung, program director at Partners in Health. “There is a huge untapped resource of people in America if we ask. “

Utah has also taken action, reassigning government employees to increase contact tracing capacity, said state health department spokesman Tom Hudachko. The heads of state are trying to gather 1,200 additional workers. San Francisco is trying to build a 150-person contact research team with city librarians, university staff, and medical students.

“There has to be an intensive course on contact tracing because many of the health services where this is going to have to happen are already a bit flat to try to respond to the current crisis,” said Tom Inglesby, director of Johns Hopkins Center for Health Security.

Experts have proposed transforming the Peace Corps – which suspended global operations last month and recalled 7,000 volunteers from America – into a national response force that could perform many tasks, including contact tracing.

On Wednesday, the editor of JAMA, a major medical journal, proposed to suspend the first year of training for 20,000 American medical students and deploy them as a medical corps to support the “testing, tracing, monitoring and quarantine ”.

The health workers who conducted this type of contact tracing for sexually transmitted diseases proposed to expand an existing group of national disease investigation specialists – about 1,600 CDC-funded workers focused on diseases such as rectal gonorrhea – a tracing of ready-to-use coronavirus battalion. The national organization for local STD programs says that $ 200 million could add about 1,850 specialists, more than double the current workforce.

There is an application for that

Technology could also prove to be crucial. But the invasive nature of tracking cellphones and apps raises concerns about civil liberties.

Technology could offer a version of what contact tracers do during interviews: create a contact history for each confirmed patient and find those who could be exposed.

Doing this digitally could make the process faster – essential to contain an epidemic – and less laborious.

Singaporean police, for example, used images from security cameras and ATMs and credit cards to track people down during the coronavirus epidemic.

Authorities in China have combined the country’s vast surveillance device with mobile phone applications and data to track people’s movements. If a person you meet is later confirmed as infected, an application warns them to stay at home.

South Korea and Israel have also deployed mobile phone applications and technology. In Taiwan, authorities have even placed virtual fences around people quarantined at home, alerting authorities if quarantined residents are trying to leave their homes or turn off their phones.

Twenty tech companies in the United States are trying to build a contact tracking app using geolocation data or Bluetooth pings on cellphones, said Dylan George, a former senior administrative policy advisor Obama, who now advises such an effort.

Seattle-King County is in “very early discussions” with a group on the use of such contact tracing technology, said Jeffrey Duchin, a senior county health official. Duchin said he would welcome any means of speeding up his team’s contact tracing work, but said, “We have no real experience with them and we cannot predict how well they will work. “

“These apps don’t solve the problem by themselves, but they can certainly help as force multipliers,” said Crystal Watson, a Johns Hopkins researcher specializing in public health preparation. “The problem is that they come with huge warnings about civil liberties that have yet to be settled. “

Yasmeen Abutaleb, Juliet Eilperin and John Sullivan contributed to this report.


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