Lesson From Singapore: Why We May Need to Think Bigger

Most parts of the world, including the most severely affected United States are now reporting either a stagnation or a decline in the number of daily new cases, prompting talks of return to normal life. Given this has been achieved through stringent lockdown measures, such decisions of returning to normalcy need to factor in the possible rebound in infection rate with social distancing relaxed. However, Singapore’s experience where the last few days have seen a sharp acceleration in reported cases doesn’t lend much confidence to the prospects of a return to normalcy. Indeed, this piece in the NY Times suggests that the path to normalcy will likely involve “a plan on a scale that would previously be considered unimaginable.” The author explores three such seemingly outrageous plans. First, the Romer plan of maximum testing where the Nobel winning NYU professor proposes to test as much as 7% of the population every day, ambitious for the sheer scale proposed. Second, The Center for American Progress plan to contact trace through mobile phone based surveillance, the resulting privacy related outrage. Third, the PolicyLab focus on universal community-level surveillance. Whilst this piece was written before the spurt in cases in Singapore, it has only reinforced the message that a system as well managed as Singapore is unable to control the situation and has had to implement forced lockdown eventually.
“Paul Romer, a Nobel-winning economist and N.Y.U. professor, proposes that 7 percent of the population be tested each day. If put on a rotating schedule, that would mean everyone would be tested roughly once every two weeks. He argues that even if there are plenty of false negatives, if we committed to isolating everyone with a positive test, we could keep the vast majority of Americans out and about in normal life. All told, that would mean 150 million tests a week. Critics will argue that’s impossible. We cannot even seem to manage a million a day. They say we lack the materials, as well as the reagents for chemical analysis, the delivery infrastructure and the machines to run so many tests. Mr. Romer is not dissuaded. “I’ve been focused on a single idea my whole career, that just because something is unfamiliar doesn’t mean it’s impossible,” he said. “Building interstate highways, scanning every book, going to the moon — these were all outrageous ideas at one time. But if we put enough resources and our minds behind it, we are able to make the impossible possible.”
… Other ambitious ideas can be found in a plan from the Center for American Progress, written by Dr. Emanuel and colleagues. Part of the proposal is an enormous information technology monitoring system. It would call for all Americans to download apps to their phones that would monitor where they go and whom they get near, which would allow contact tracing to be done instantaneously. Everyone could sign in electronically before using public transportation, entering large buildings or schools or gathering in groups above a certain number. They even propose requiring the app to be downloaded in order to receive test results. In an ideal situation, it would run in the background, regardless of whether users signed in. “If we could do real-time contact tracing based on a person’s phone and GPS signals, and alert people that they have been exposed to a Covid-19 positive person,” that would greatly ease the containment strategy, he said. Of course, such a system would be considered a large intrusion on privacy, and it’s not clear it is politically feasible — or even legal.     
… “A more realistic and useful approach would focus much more on surveillance, monitoring communities more than individuals,” she said. As detailed in a PolicyLab Policy Review, such surveillance could relax our need for active testing. It would be more reliant on passive systems, like monitoring electronic medical records or traditional infection monitoring systems to pick up signals for outbreaks, like increased visits to doctors or emergency rooms for respiratory illnesses. Surveillance could also involve a “participatory approach,” like asking patients to be tested before clinic visits, or to enter symptoms on web-based tracking platforms, or to regularly check their temperatures at home. Thermometers would be ubiquitous, and could even be linked to the internet for reminders and reporting. If such systems work well, we don’t need to capture an entire population to detect a signal. We could identify hot spots, telling us where to do more focused testing. Such testing could even be done by pooled samples. In such an approach, areas would have their individual samples combined together for testing, which saves resources. If it’s clear, everyone is safe. If an infection is found, then — again — more focused testing could be done on the individuals in the pool. The PolicyLab review also highlights the benefits of improving workplace safety, especially in high-risk areas like child care, school and health care environments, to make infection control more robust and surveillance easier to accomplish.”