By Francesco Lapenta, professor and director of John Cabot University Institute of Future and Innovation Studies in Rome
Analysis. The early response to a unique, but not unprecedented or unpredictable global biological crisis has been chaotic, profoundly un-collaborative and characterized by individualistic and nationalistic rather than collaborative, altruistic, and coordinated responses. This was particularly evident in Europe, where European countries instead of coming together, in a real betrayal of the most idealistic dimension of the European Project, closed down in self-protection and struggled to find a common response. One by one all other countries and nations followed in this process of self-isolation. One virus, the same virus, has been able to quickly spread all around the world with the same patterns of contagion, symptoms, illness and possible death. One common problem for humanity that affects us all, and five months later the absolutely identical challenges the virus poses to all, have led to a mostly fragmented, uncoordinated, incoherent set of national and local efforts and responses.
National borders have been closed, exchanges of crucial supplies denied, many basic accomplishments of globalization suspended, and the already fading trust in the positive outcomes of globalization itself ever more profoundly questioned. A global common biological crisis, the same virus, suddenly chaotically perceived and treated like a contingent threat to national interests, international power relations and a cultural problem. One scientific common problem, yet generating many different socio, economic, cultural evaluations and national responses.
The forcefully autocratic Chinese response. The experienced and well organized South Korean response. The early utilitarian British response. The dramatic and emotional Italian response. The pragmatic well organized Teutonic response. The North American and Southern American sociodemographic and institutional-structural crisis. The arrogant if not irresponsible Swedish blasé. Fragmented interpretations and culturally different responses, governed by historical and cultural inclinations, national strategies, socio-economic evaluations, existing and new power relations, and personal political opportunism and gain. A dangerous mix, and a global social confusion, in which dangerous politically opportunistic strategies can be imposed for reasons different from those of tackling a common global biological threat. A mix in which the methodic quest for a shared scientific solution, based on “the rigorous clinical testing and factual deduction that is at the heart of generations of advances in clinical science and is the bedrock of ethical medicine” ( Stephen Collinson 2020) has been drowned in chaotic and different political responses mostly characterized by un unprecedented suspension or erosion of existing freedoms. A real opportunity for rogue governments to impose persistent restrictions to individual freedoms that would have met much stronger resistance in different circumstances. And a real danger for democratic societies to loosen up on the ethical issues already challenging their societies. It is in this struggle between science and politics, and the danger of an uncoordinated and not scientifically or politically accountable, and limited, response that we need to analyze the theoretical advantages, and the very real risks, of app based contact tracing
The Scientific Framework of App-Based Contact Tracing
There seems now to be an agreement on the fact that the global pandemic crisis will only be solved by the combined efforts of a vaccine, and/or an effective medical treatment able to avoid death for most of the serious cases of Covid-19 infection. A combination of medical goals on which the medical community is working feverishly, but that will require a significant amount of time. An excruciating time gap that is leaving the world’s governments and their societies to find solutions to mitigate the devastating effects of Covid-19 on health and the economy. Two almost inconceivably competing missions, where any space conceded to one will affect negatively the other. Lock down, wash your hands, social distancing, flatten the curve, wear your masks and gloves have all become too common a lexicon in this excruciating research of temporary survival strategies. All solutions competing with an ever increasing list of other scientific or sudo-scientific measures to limit the spread of the pandemic. It is in this context, while waiting for a reliable medical solution, that another strategy, app contact tracing, has become yet another, imperfect as the others, proposed remedy for these strategies of mitigation.
This is the theory behind the use of “App based contact tracing” in brief. There seems to be scientific agreement on some basic facts about the virus transmission patterns (Ferretti and Wymant 2020). There are four identified cases of transmission. In order of greater incidence we have: a) Symptomatic transmission. b) Pre-symptomatic transmission. c) Environmental transmission. d) Asymptomatic transmission.
Pre-symptomatic conditions are characterized by an incubation period of around 5 days between the time of infection and onset of noticeable symptoms. Transmission by symptomatic individuals (a) is thought to be the strongest. However, pre-symptomatic transmission (b) appears to be very substantial too, and accounting for a third to a half of transmissions. While it is possible to isolate and quarantine individuals that present noticeable symptoms or have been diagnosed with the virus. A significant number of individuals whom are still pre-symptomatic are capable of spreading the contagion without being detected. The combination of these two forms of transmissions, without severe contact and movement restrictions to limit them, and quarantine measures, are strong enough to guarantee the further increase of the pandemic. Environmental transmission (c) is meaningful but thought to be significantly inferior in comparison. Onward asymptomatic transmission (d) seems to be uncommon and to have a low incidence (with an important caveat that children could be frequent asymptomatic carriers). Quarantine measures, are based on contact tracing, where both the symptomatic persons and the people whom they have been in contact with (and traced) are put is self-isolation. Manual contact tracing of people whom have been in contact with pre-symptomatic and symptomatic individuals is very costly, complex and basically ineffective given the numbers of people infected and method. This method would entail to establish, post facto, a contact trace based on individuals’ interviews, and their recollection of contacts and movements in the past 5, 6 days before diagnosis. Not fast, precise or comprehensive a task, nor feasible.
The theory on which “App-based contact tracing” is based upon is theoretically simple. It is based on the use of an App that keeps a detailed record (via GPS and Bluetooth) of movements, and proximity events between two or more individuals, whom have no symptoms (yet). The GPS data will provide detailed information about the position and movements of an individual, and the Bluetooth proximity pairing of two individuals’ mobile Apps will provide a record of all proximity contacts. Once a case of Covid-19 infection is diagnosed, or an individual displays noticeable symptoms, the App can immediately alert recent close contacts and prompt them to self-isolate. The theory is that by combining the isolation of symptomatic individuals, and the individuals they got in contact when they were pre-symptomatic, we can control the spread, and the curve, of the pandemic. An elegant technical solution, it seems, but with a real set of risks, and technological and ethical limitations when you analyze it in the geopolitical context and diversity described above.
The Limits of App-Based Contact Tracing
There are a number of problems with App based contact tracing that pose serious questions about their effectiveness. Some are simply methodological and statistical. The effectiveness of these Apps is fundamentally based on the quantity and quality of data they use. To work they need to have reliable data on the individuals that use them, and to be effective they need to be combined with a statistically meaningful number of diagnostic and serological tests. Diagnostic and serological tests are different, and show if you currently have the coronavirus, or if you have previously had it. Testing procedure are costly and time consuming and notoriously difficult to methodically administer on an entire population. Without these reliable data on a vast percentage of the population these Apps would be very ineffective.
Another problem is social acceptance and adoption. On a technical level, the distribution of advanced smartphones worldwide is uneven at best. And at a general level the social acceptance and adoption of these Apps is problematic and cannot be taken for granted, tapping on local social sensibilities, trust, and orientation to privacy. Governments whom decide to use these tools have two options, to either suggest the voluntary use of these Apps, or to impose them. Both approaches are problematic for different reasons, we will see. But the problems don’t finish there. What real purpose do these Apps have, if information cannot be globally shared. What happens if we move back to a situation where national borders are opened again, and people start again to move from country to country. In a typically uncoordinated fashion, all nations and governments that are evaluating the adoption of App-based contact tracing (or have already adopted them) are doing so at a national level. With many considering the data collected by these Apps a national property and a national security risk. And once again not considering the global nature of the pandemic, and the fact that if we were to adopt App-based contact tracing as a possible effective solution, a globally shared solution should be found.
The Ethical Implication of App-Based Contact Tracing
It is only natural that in such a moment of crisis society should resort to all technological tools at its disposal to tackle the pandemic, and there are certainly good reasons to do so. It remains paramount however to remain vigilant that such technical solutions are efficient, balance prospective gains with costs, and abide to established ethical and legal principles and designed to address the real risks of possible abuse. Successful and appropriate use of App-based contact tracing should rely on public trust and confidence in robust technical solution. This applies to the App itself and to the treatment of the data gathered.
Ferretti and Wymant call for a set of criteria or requirements to be fulfilled for the adoption of trustworthy contact tracing apps. Many of these requirements are also consistent with many of the requirements described by DataEthics.eu in their white paper on public procurement (Hasselbalch, Olsen, Tranberg 2020). They suggest that “requirements for the intervention to be ethical and capable of commanding the trust of the public are likely to comprise the following:
i. Oversight by an inclusive and transparent advisory board, which includes members of the public.
ii. The agreement and publication of ethical principles by which the intervention will be guided.
iii. Guarantees of equity of access and treatment.
iv. The use of a transparent and audible algorithm.
v. Integrating evaluation and research in the intervention to inform the effective management of future major outbreaks.
vi. Careful oversight of and effective protections around the uses of data. vii. The sharing of knowledge with other countries, especially low- and middle-income countries.
viii. Ensuring that the intervention involves the minimum imposition possible and that decisions in policy and practice are guided by three moral values: equal moral respect, fairness, and the importance of reducing suffering.” (Ferretti and Wymant (2020).
These represent a tall task to accomplish, but they constitute a meaningful set of guidelines for all governments whom will eventually understand that a real solution to a global problem can be achieved only with shared ethical solutions. That digital contact tracing might ultimately be ineffective, or limited in its effectiveness to curb the pandemic, while it is certainly more risky and in its power to constitute a meaningful precedent of social surveillance and control and that for this very reason should be treated as the most urgent and meaningful test of the possible use of collective information gathering for a coordinated solution to a global problem. A test bed for value driven design. An exercise in transparency and public governance. A dynamic state – citizen, and citizen to citizen form of collaborative interaction, as well as a small contributing strategy, that along with other strategies, work towards the containment of a global health care crisis until a more permanent and effective solution is found by rigorous clinical science and ethical medicine.