The United States now has more cases of COVID-19 than anywhere else in the world. As each day brings ambulance sirens and unexpected obituaries, many strategists are studying what places like Taiwan did to keep their COVID-19 infection rates remarkably low using a combination of travel shutdowns, widespread testing, and clever technological solutions.
America’s health tech rollout has been more haphazard and less impactful than what was implemented in several parts of Asia. How were Taiwan, Singapore, South Korea, and other countries able to quickly crank out apps and platforms that saved lives?
“This last war came back and they were ready”
“As humans, we’re all just wired to be fighting the last war,” says attorney David Harlow, who advises healthcare companies. For several Asian countries, that last war was the 2002 outbreak of Severe Acute Respiratory Syndrome, aka SARS. After the spread of that virus — which infected over 8,000 people and killed almost 800 — many countries, including Taiwan, instituted measures such as taking passenger temperatures at airports to check for signs of virus. “This last war came back and they were ready,” says Harlow.
In the early 2000s, the United States had about 150 cases of SARS, and that small number may have left the country relatively unprepared for its current battle with COVID-19. The United States’ Hunger Games-style response to the pandemic, in which individual states vie for medical supplies, seems to parallel the federal coordination of the tech community, in which researchers work on similar ideas in separate labs and hackathons.
How tech has helped overseas
In several of China’s neighbors, tech — from quickly cobbled together apps to widely available forehead-scanning thermometers — played a vital governmental role in tracking virus carriers, uncovering potential patients and supporting quarantine measures. At the U.S. federal level, there have been relatively few tech rollouts, and the ones that have happened, like the early COVID tests created by the Centers for Disease Control (CDC), have been botched or underwhelming.
“We knew this was coming,” says Steve Davis, co-chair of the World Health Organization’s (WHO) Digital Health Technical Advisory Group. “We saw the cases in China, we knew that we were underprepared for an epidemic of this proportion in this country.” In the first week of February, Davis discussed the Wuhan outbreak with several congresspeople as part of the Commission on Strengthening America’s Health Security — a panel hosted by the Center for Strategic and International Studies.
The WHO’s Digital Health Technical Advisory Group is working with the CDC, foundations, and various national governments to recommend tools that have worked in some countries and connect people with designers and developers. But they can only recommend, not demand, rollout. Given that President Trump is publicly feuding with WHO, it’s hard to imagine that the White House will readily embrace its advice.
In China, for example, Tencent built an app geared at students asking them to fill out their daily temperatures and obtain a color-based QR code showing their health status. The company also developed a health portal with information about COVID-19, including a map that works with its WeChat messenger and shows which communities have cases and their physical distance from the user. The CDC also has a symptom checker, but it doesn’t have as much real-time information such as updated numbers on positive tests. Davis says Tencent’s technology is now being adapted for India.
1,000 great ideas
A lot of other companies, including many in the U.S., are working on innovative ideas, but not necessarily ones that can be launched quickly with the promise of easy, widespread adoption. Facebook, Johns Hopkins, and even Lady Gaga have all announced hackathons and funding initiatives, but the results of these coding jamborees are likely months or years from launch.
In one of the most lauded projects, Alphabet has coordinated with the California governor’s office to let people sign up for free COVID-19 tests as part of Project Baseline. It’s an impressive initiative, but only available in a handful of California counties. A group of senators has also sent a letter to Alphabet (Google’s parent company) asking for details about how Project Baseline is safeguarding the information it collects. At one point, the federal government said it was going to stop funding for local coronavirus testing sites, but then reversed its decision.
Davis commends all of the developers grinding out code and envisioning world-changing initiatives, but also notes the inherent challenges. “It’s a luxury and it’s a problem because, of course, you have 1,000 ideas being jammed into a system that’s under enormous stress,” he explains.
Some of healthcare’s tech problems are well established. Many hospitals and medical offices stagger along on outdated systems that still rely on faxing and paper records, which makes it tough to keep track of COVID-19 test results and get reliable numbers on burgeoning hotspots.
As part of a single-payer universal health system, Taiwan has a National Health Insurance Database that maintains claims and enables the Ministry of Health and Welfare to give researchers access to important data about symptoms cropping up in local populations. Once the symptoms of the novel coronavirus were understood, patients with respiratory issues who tested negative for the flu were later contacted and checked for COVID-19.
The CDC’s National Syndromic Surveillance Program, which was developed after the anthrax attacks of 2001, gets updates from emergency rooms in 45 states, but the information isn’t nearly as comprehensive as what’s in Taiwan’s system.
To coordinate government initiatives, Taiwan launched a Central Epidemic Command Center in January. Politicians from the ruling Democratic Progressive Party use their Facebook, LINE, and YouTube accounts to share policy updates and even details about the number of available face masks.
In the past couple of weeks, the CDC has been advertising on YouTube, Spotify, and other social media to spread the word about staying home. President Trump has used his Twitter account to remind people to stay home, as well as rail against governors who complain about the federal response to the pandemic and downplay the threat.
The line between safety and surveillance
Taiwan also took steps that are unlikely to ever get adopted in the U.S., given what is politically and culturally acceptable on this side of the Pacific. There, a scheduled air passenger is expected to go online and report his or her recent travel history and get a travel risk assessment, which is connected to a QR code to be shown before boarding a plane. Many U.S. airlines don’t even collect complete contact information of their passengers, complaining to the government that it would take too much time and extra money to do so.
Taiwan’s infection control hotline, 1922, allows callers to report not only their own personal health concerns but also problems they suspect in neighbors, friends, and, well, anyone. Describe 1922 to any fan of dystopian literature and their eyes will be filled with visions of Orwell’s 1984. Many see China already taking advantage of its like-minded virus outbreak apps to increase citizen surveillance. Moscow brass has employed its system of 170,000 surveillance camera to look over everyone’s shoulder and check for people violating quarantine.
Could tech similar to the 1922 hotline ever be allowed in the U.S.? “It seems unlikely if we think about it in terms of a healthcare situation,” says Harlow, who’s currently the Compliance and Privacy officer at Insulet. “If we think of it in terms of a public emergency situation, which is what it is right now, then it’s sort of a different conversation. And then perhaps it’s no different from making a call about someone with a loaded gun.”
New York Mayor Bill de Blasio recently announced that the city’s 311 complaint line could be used to report instances of problematic social distancing, and citizens will soon be able to upload photos of bunched-up lines and open nonessential stores to the 311 app.
A comprehensive response
In the Journal of the American Medical Association (JAMA), Dr. Jason Wang detailed Taiwan’s use of technology in the paper “Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing.” As part of the report, Wang includes a list of over 100 actions Taiwan’s ministries took from Dec. 31 to Feb. 24 to ensure the safety of its population, including issuing mobile phones to people who were assigned home quarantine to track their movements. Anyone who violated his or her quarantine could be fined up to $10,000 (and many were).
Never gonna happen in America, right? A Kentucky judge recently ordered an ankle monitor for “D.L.,” a Louisville resident who tested positive for COVID-19 and, according to his family members, left the house often. At least two other locals who have tested positive or been exposed have been tagged with monitors.
Wang recommends that America and other countries adapt Taiwan’s protocols “according to their social context and available resources.” He also says that the government should have arrangements in place with telecoms to make national announcements akin to Amber Alerts.
The U.K. and other countries have sent nationwide texts to mobile phone users about the novel coronavirus. America has presidential phone alerts that can be texted nationwide, but haven’t been utilized during the epidemic. The FCC hasn’t recommended that public safety agencies use their Wireless Emergency Alerts to warn about social distancing, but has reminded them they can do so if they want. According to CTIA-The Wireless Association, more than 100 COVID-related wireless emergency alerts were sent before April 1, but it’s unclear who the originators are.
Who holds the info?
South Korea has use widespread free testing and several apps to push back on a national outbreak that was once one of the largest in the world and is now one of the lowest. How did they turn things around? Routes taken by positive patients are published online. International travelers must sign onto an app and report their daily symptoms. Location-based text alerts are sent to phones about nearby confirmed cases — and no one is allowed to opt out from receiving them.
In the U.S., the launch of such technology would likely be the start of 1,000 lawsuits.
“The questions become: ‘Who is holding all of that information? How anonymized or de-identified can it be and still remain useful?’” says Harlow. “The more deeply you anonymize something, the less functionally useful it may become. But there is the possibility that you could design such a tool, roll it out, and with the appropriate disclosures and options and trust environment, then there’s an opportunity to use technological tools in a way that can help individuals manage their own risks.”
CoEpi, short for Community Epidemiology in Action, is an app attempting to fill that need, to be a “privacy-first system for anonymous Bluetooth-based contact tracing.” (You can currently sign up to be a beta tester.) MIT has developed a similar application that programs phones to emit anonymous and inaudible “chirps” that will alert other users if they may have been exposed to someone with the virus. Of course, the success of such a system requires that a lot of people know about the app, sign up, willingly upload their diagnosis and probably sign off on a long privacy waiver.
“If you have the ability to require people to opt in, as perhaps is the case in a government-sponsored app in an Asian country, then then you have a different possibility of having more comprehensive coverage on the data,” says Harlow. “In the U.S., how much are we going to waive today that we’re going to wish we didn’t waive months or two years from now?”
In mid-March, TechCrunch reported that government reps were in talks with Facebook and Google to use cell phone data obtained by the companies to help fight the pandemic. Later, Facebook denied the report and that they were using anyone’s private information. Since then, Apple and Google announced that they plan to team up to launch a contact-tracing app that will embed into Android and iPhone devices. It promises to be the one of the most far-reaching tech efforts to date, but may take several months to get to market.
In the meantime, New Mexico has been using cell phone data provided by Santa Fe’s Descartes Lab to check if people are adhering to social distancing. The info may be used to change traffic patterns. Similar cell phone mapping projects shined a light on all of the spring breakers partying on Florida beaches. So far, such tracking has been used to make grand statements rather than nudge individuals.
Post-peak solutions
At the World Health Organization, Davis is working with his panel to figure out which of the thousands of platforms and apps currently being programmed around the planet will be the most impactful. (The organization also has an open source Covid-19 Tips app its working on.) In addition to the previously mentioned programs, South Korea also has ones for hospital case management. China is testing digital tools that manage who’s safe to get back to work. Several U.S. think tanks are proposing the deployment of mobile apps with personal risk assessment QR codes, similar what’s been used in Taiwan.
“How do you control the safety of the country beyond the peak?” says Davis, looking forward to that time when countries are “over the hump” and ready to reopen.
He’s also worried about countries in Africa and other parts of the world that are just starting to have small flare-ups and may not have the resources to develop technology in a matter of weeks, as has happened in Asia.
“We hope we can leverage the existing tools and apply them more directly,” he says, noting that much of the current technology in different countries is still “homegrown.”
Having worked on containing the Ebola outbreak, Davis knows it’s unwise to throw a lot of new apps at a fragile digital ecosystem. The numerous updates and changes that often come along with startup projects can be difficult to manage when the users aren’t all on new technology and ready to update programs at a moment’s notice.
Reflecting on the world’s larger health issues, he also fears that the money and attention placed on COVID-19 may distract from other concerns such as malaria, which continues to kill about 1 million people per year.
As for the U.S., at least one big question remains: If the feds rolled out a tracking app similar to what has been successful in Taiwan, South Korea, and Singapore, would Americans accept it?
“We have a fairly high percentage of folks who just don’t trust the government,” says Harlow. “That level of distrust goes hand in hand with a failure to comply with voluntary shelter-in-place directives right around the U.S. — people are still going to the beach for spring break. If you’re living in Singapore, you couldn’t really do that. You’d get arrested in about a minute.”
