The Federal Government vs. the States

As COVID-19 continues to spread, with some of the highest rates of daily infections yet, the country faces a winter — the height of cold and flu season — that could exacerbate the spread of the virus. The promise of a vaccine is still months away, and public health experts have repeatedly stressed the importance of robust contact tracing to help stop the virus from infecting and killing even more Americans.

But, as with nearly every aspect of the federal government’s response to the pandemic, the Trump administration’s and the CDC’s efforts at contact tracing have been minimal at best, and nonexistent at worst. Instead — as with mask mandates, testing regimens, and decisions on reopening the economy — it has been up to states and localities to implement contact tracing programs.

Amid this chaos, some experts and public health professionals have begun to look toward technology to bolster contact tracing — a tedious and time-consuming process that requires tracers to contact infected individuals and politely interrogate them about who they’d come in contact with in the days leading up to their positive diagnosis.

In April, Apple and Google made a framework available that would allow phone users on either company’s operating systems to participate in an exposure notification program that would use Bluetooth technology to constantly ping nearby phones. If a person received a positive diagnosis, they can choose to have their anonymized device added to the list of positively diagnosed users. Those whose phones had been in close proximity would then automatically get an alert that they’d been exposed. So far, thirteen states have made the technology available with different criteria, according to 9 to 5 Mac.

Four states — California, Maryland, Oregon, and Washington — as well as Washington, DC, have apps in development. But in many places, especially in the South and in Republican-led states, contact tracing lags woefully behind, according to TestAndTrace, a volunteer-based website led by members of the tech industry and academia.

In Rhode Island, where the CRUSH COVID RI app has been downloaded some eighty thousand times, a Department of Health spokesperson told the Daily Poster that the app has been “highly beneficial” in helping prevent the spread of the virus, because users of the app are able to provide contact tracers with their precise locations in the app’s “My Location Diary.”

Outside the United States, countries like Singapore, China, and South Korea have had some success with digital contact tracing as an augmentation to traditional methods. (Of course, constant tracking in authoritarian places like China poses worrisome privacy concerns beyond COVID-19.)

Ireland, which has now connected its COVID app to apps in Germany and Italy, was looked to not just by Pennsylvania but also by Delaware, New Jersey, and New York.

One exchange shows how difficult such collaboration will be in the United States in the absence of federal leadership. One email to Patel from Israel Soibelman, a leader on the project from MIT’s Lincoln Laboratory, shows how the federal government’s absence, paired with reliance on contracts and relationships with the private sector, slowed down the development of Pennsylvania’s contact tracing app.

“They told us they were looking for states to collaborate with on a pilot and asked if we had thoughts,” Soibelman explained of the CDC. “I hope this is ok but I told them how impressed we were by how PA has put their thoughts together on this area and suggested they contact you.”

Patel then asks what the CDC’s expectations are.

“They understand that some states because of political pressure are moving very fast to have an app so they want to move quickly with a pilot so they don’t miss the boat to help them,” Soibelman writes, noting that digital contact will be important in “preparation for any fall spike.”

A Pennsylvania Department of Health spokesperson said that the CDC had helped with the state’s efforts through its ELC grant program. Its role in a “pilot” initiative is not clear.

Rather than seeing the issue as “political pressure” from some states over others, as Soibelman put it, the virus should have been seen as a collective problem to solve among state, federal, and private-sector actors, experts like Kahn and others told the Daily Poster.

“We’re going to need contact tracing capability for the long haul,” said Mike Reid, a University of California-San Francisco medical professor who has been working as a contact tracer in collaboration with the state’s department of health. “I think this is a failing of the current administration to invest in the basic things you need in the face of a pandemic.”

Contact Tracing vs. Politics

Leaders in Republican states, who view the public health crisis as a political issue, have been loath to take robust action to combat the spread of the virus, including efforts on contact tracing.

In South Carolina — one of the last states to shut down and the first to reopen — governor Henry McMaster, a Trump ally, has had a detailed proposal for an innovative digital contact tracing regimen on his desk for months.

State officials were presented with a plan to implement the Apple-Google framework in a way that favored the private sector and left the government mostly out of the process, according to an analysis of documents obtained under a separate South Carolina open records request.

But the governor’s office and legislature have apparently had no public debate about the plan and have failed to implement it. The details of the Medical University of South Carolina (MUSC) plan, called “SC-Safer-Together Contact Notification System,” have not been previously reported.

The program would work like this: Those who are directed to get a COVID-19 test would be asked by their medical provider to download an app on their phone. The app would use the Apple-Google framework in conjunction with health facilities’ health records to anonymously notify other app users if a person had tested positive. It would then track the infected person’s progress, including further tests.

The South Carolina proposal also calls for physical Bluetooth “beacons” to be placed in homes, offices, schools, and places of employment, like grocery stores. If infected app users passed by a beacon, managers of facilities would be notified and could voluntarily alert health officials and their employees.

“If successful, the system will not only engage patients and community in both prevention and care of COVID-19, but it will also help public health and employers and school systems manage outbreaks and perform contact tracing within their own environments,” the authors of a MUSC research paper on the program wrote.

Dr Leslie Lenert, the lead author of the MUSC paper, said in an email that he has been “instructed not to discuss this” and that it “remains a sensitive issue with our legislature.” He declined to speak further about his research.

A coauthor of the paper, Richard Brooks, a Clemson University professor who has worked on various privacy issues with the federal government, said in an interview that he believes the plan should include notifying local health authorities when spikes occur.

He declined to discuss the plan in detail but said, “Why not allow individuals to take control and participate in things like this if they want to protect themselves and their families?”

There is no indication that South Carolina has moved forward with the proposal. McMaster’s office did not respond to a request for comment, and reports that the state would work on its own app based on the Apple-Google framework may have been “premature,” Brooks said.

One Failure Among Many

The Pennsylvania emails show how alone Patel was in her quest, and how difficult it was for an individual state health department to coordinate a consortium of groups from the Private Automated Contact Tracing (PACT) group at MIT.

Despite the odds, Pennsylvania rolled out its app in September.

The barriers Pennsylvania faced, though, are indicative of the federal government’s overall response.

An extensive report in ProPublica details the pressure from the White House to downplay the threat of the virus, with high-level scientists stymied across the board. In May, more than one thousand former CDC officials from Republican and Democratic administrations signed an open letter decrying the failure of federal leadership on the virus.

“[S]tates and territories have been left to invent their own differing systems for defining, diagnosing and reporting cases of this highly contagious disease,” the former officials wrote.

Despite the lack of a true federal partner, states like Pennsylvania and others have been successful in pushing for a common framework that can work across state lines and a unified server launched by the Association of Public Health Laboratories, according to Recode.

So far, Pennsylvania’s app has been downloaded 351,000 times, with twenty-three notifications of potential exposure having been sent to app users, according to a health department spokesperson.

But digital contact tracing is no silver bullet, experts warned. Like masks and shutdown orders, apps that track users’ location could easily become politicized, said Kahn, the Johns Hopkins professor who coauthored a recent book on digital contact tracing.

Kahn and others said that what could truly help bring the virus under some semblance of control is effective federal leadership — a conclusion also reached by an Irish official working with Pennsylvania.

“For the US, [we] suggest you agree [to] one entity to host the federated server and each state / public health system build the solution on one backend server, if that is feasible,” he wrote of the logistical hierarchy of a nationwide digital contact tracing system.

While Patel was not made available for an interview, her urgency in some emails was striking. She wrote to the CDC in late June that the application could help, and that the state needed to move quickly, as hospitalizations were on the rise. “With schools and colleges openings around August and after utilizing all the tools in the toolbox, our leadership is keen on utilizing this tool,” she said.

The CDC, of course, could have very well been the one sending a similar email.

“If it was just a question of contact tracing, you could give [the Trump administration] the benefit of the doubt, but the entire response to this virus has been insufficient,” Kahn said. “Yes, there should be a coordinated response from the federal government on digital contact tracing. Instead, tech companies have done the work of the CDC.”