“Given that we still face months of potential chaos and damage, we have to understand why the government keeps ignoring well-established principles of good practice, and why it is willing to hand over contracts to companies such as Serco rather than involving local public health systems from the outset. This is not a case of mistakes being made. Instead, the government’s contact tracing shambles suggests something more troubling: a disdain for evidence, an obsession with centralised control, and the privileging of private over public interests.”
Why we got test and trace so very wrong
Most people agree that England’s handling of the Covid-19 crisis has been slow and disorganised; a fact made worse by the government’s willingness to squander public trust by massaging data and spinning the facts to save face. Yet its shambolic approach to testing and contact tracing isn’t the result of mistakes, but a choice to ignore evidence and experience.
For months, public health specialists in England have asked the government to decentralise responsibility for testing and tracing to local authority public health teams, which can develop nimble and responsive plans that are specific to different contexts, and organise systems with clear lines of accountability. They have also asked the government to recognise the obvious fact that case detection and contact tracing are social and behavioural interventions, which rely on skilled personnel and trust.
Take the detection of coronavirus cases – a fundamental part of preventing the spread of the disease. Because speed is critical, we can’t passively wait for people to present themselves at a drive-in centre for testing. We need to actively look for people across the population who may be infectious and encourage them to be tested. The sooner cases are identified, the quicker they can be quarantined, and the fewer contacts there will be to trace. This is why countries such as Singapore and Taiwan implemented rigorous screening programmes in airports. They didn’t wait for the virus to appear in a clinic or hospital – they went looking for it.
Testing is particularly important with coronavirus, because many people have mild or no symptoms. Actively detecting new cases through testing also allows public health authorities to visibly demonstrate the importance of vigilance, and provides an opportunity for frontline health workers to engage with communities. Ideally you want to target communities or population groups who are at risk of either getting a severe infection, or transmitting the virus to others.
In Vietnam, screening programmes initially targeted incoming passengers at airports who had to agree to a temperature check, and fill in a form giving their contact details and travel and health history. These measures were then extended to anyone entering a major city, government building or hospital. Anyone with suspicious signs or symptoms, such as a temperature over 38C, was taken to a medical facility for thorough testing. Accessible testing stations were also set up across cities, while banks and apartment complexes established their own screening procedures. Likewise, Germany developed an aggressive case-detection strategy, testing anyone with symptoms and using a public information call centre to direct people to nearby local testing centres.
You also need a well-trained workforce, able to engage with people on a human-to-human basis, with some epidemiological and clinical knowledge. Because testing results aren’t always correct and can be delayed, sometimes a presumptive clinical diagnosis – of the sort a trained health worker can provide – is necessary. And when a case has been identified, information needs to be carefully gathered and assessed to determine the likely period of infectiousness, identify high-risk contacts (those who have had close and prolonged interaction, especially in a confined indoor space) and then formulate a tracing plan. Conversations need to be empathic and culturally sensitive, and conducted in the right language.
In Vietnam, teams of professional health workers, supported by civil servants and other recruits, delivered a programme of case detection, contact tracing and quarantine enforcement that was pivotal to bringing the virus under control. Kerala state in India is another success story: it acted quickly to minimise the spread of the virus by screening people in airports, seaports and railway stations. Kerala’s extensive community-based primary healthcare workforce helped to identify suspected cases and followed this up with nuanced conversations about the risk of spreading the infection to others. Because capacity was limited, testing was directed primarily at those with symptoms.
The workforce needs to be trusted, as well as skilled. Contact tracing involves sharing and divulging sensitive personal information about other people, some of whom will be subsequently inconvenienced by having to go into quarantine. People are more likely to cooperate and adhere to required behaviours if instructed by someone they trust who is clearly working in their interest. In Kerala, citizens trusted the state’s visible public health leadership and its decentralised health system (every town and village has a primary health centre, which has strong links to local communities).
For some reason, these basic principles eluded policymakers and public health professionals in England. Where Germany worked through a set of 400 decentralised teams, we decided to centralise our operations, a mistake that was compounded by decoupling testing from contact tracing, and then made worse by outsourcing both testing and contact tracing to private sector companies. The government also fixated on a mobile phone contact tracing app before properly establishing a human-driven and people-centred testing and contact tracing system.
Given that we still face months of potential chaos and damage, we have to understand why the government keeps ignoring well-established principles of good practice, and why it is willing to hand over contracts to companies such as Serco rather than involving local public health systems from the outset. This is not a case of mistakes being made. Instead, the government’s contact tracing shambles suggests something more troubling: a disdain for evidence, an obsession with centralised control, and the privileging of private over public interests.