As cases of COVID-19 spiral out of control in the United States, states are struggling to tackle the virus with an increasingly widespread arsenal. Many of them have the same weapons at their disposal: restrictions on public gatherings and enforcing the use of masks, as well as notifications of testing, tracing, and exposure.
But while many states struggle to make their systems work together, Guam, a small U.S. territory closer to the Korean Peninsula than the North American mainland, may offer clues on how to bring communities together. at least part of the puzzle: finding contacts on a smartphone.
Without a budget and relying almost entirely on a grassroots volunteer effort, Guam was able to convince 29% of the island’s adult residents to download its exposure notification app, an adoption rate that surpasses the states. with much more resources.
A collaborative effort
Guam diagnosed its first cases of covid in March, but a few weeks later it gained the attention of the international community and a much higher number of cases when it came to a US Navy ship. ordered to dock at the island’s naval base. Sailors who tested negative have been quarantined at local hotels and banned from interacting with civilians.
Having so many positive cases on the island showed just how vulnerable the island really is, but it also created a lot of new volunteers who were looking for ways to help.
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At around the same time, Vince Munoz, a developer at Guam-based software company NextGenSys, got a call. The island was offered a partnership with the PathCheck Foundation, a nonprofit organization that developed government contact tracing applications. Muñoz immediately saw an opportunity to help his community fight this new threat.
“It’s something you do to help others,” Muñoz says. “This allows you to reduce the spread of the virus.”
Digital contact tracing is a potentially straightforward way for health services to reduce the spread of Covid-19 by using smartphones to track who has been exposed. And while exposure notifications aren’t the panacea many technologists have hoped for, new research suggests that even breaking a few links in the chain of transmission can save lives.
So, the Muñoz team of volunteers logged in to PathCheck, which was founded in, and started building an app called Covid Alert. Like most exposure notification apps in the United States, it uses a system created by Google and Apple and uses Bluetooth signals to alert people who have crossed paths with someone who has subsequently tested positive. From there, they are advised to contact the local health authorities on the island and take appropriate action. Everything is done anonymously to protect privacy.
After several months of testing and tweaking, the app was ready. But one important piece was still missing: the users. After all, any contact tracing app needs as many downloads as possible to tell the difference. Muñoz knew the right people to create the buzz: the Guam Visitors Bureau. Tourism is extremely important to the island, which receives over 1.5 million visitors each year, almost 10 times the local population. As the pandemic approaches, the office has helped tourists plan trips to Guam’s “starry sand beaches”. The staff took the opportunity to help.
With the help of Thane Hancock, an island-based CDC epidemiologist, and Janela Carrera, public information officer for the Guam Department of Public Health and Human Services, the team began to create a marketing campaign.
“Since we had no funding, we decided to run a grassroots campaign,” says Monica Guzman, CEO of Guam-based marketing firm Galaide Group, which works with the office. “Guam is a very small community. We are all relatives, neighbors or friends.
While PathCheck and the Munoz development team worked on creating the app, the Visitors Bureau began reaching out to community groups and nonprofits to raise awareness. He received calls from Zoom with organizations, schools and cultural groups across the island with the message that the app could help remove the virus, if enough people were willing to “be a covid warrior.”
“Schools, government agencies, media, they all came together,” Carrera says.
Taken together, these efforts are part of what ethics researchers at the Swiss Federal Institute of Technology recently called “piecemeal building of public trust.” For people to use a new technology like exhibit notification, it must reach the people where they live and gain buy-in from community leaders.
It takes a village (on WhatsApp)
With the app ready to launch in September, it was time to spread the word.
The day before the official launch, Russell Ocampo, director of marketing for the visitors’ bureau, messaged Guam’s notoriously big and rogue WhatsApp groups on the app. This message bounced across the island, resulting in nearly 3,000 immediate downloads. “I’ve had it like 10 times from other people,” he says.
Another 6,000 people signed up the next day at a press conference, including the governor, who downloaded it while it was online.
The effort received a show of support that many U.S. states and territories could only dream of. The island’s three major telecommunications companies sent free text messages to encourage people to download the app. Meanwhile, a local television station organized a two-hour “download marathon” in an attempt to gain attention. The show featured performances by local musicians, interspersed with information about the app, including debunking privacy myths and other lingering concerns. Viewers had the opportunity to win $ 10,000 in prizes, many of which were personally donated by members of the Guam Visitors Bureau and others who worked on the app, if they could prove they had. downloaded the app during the show. .
The Guam Visitors Bureau has offered other cash prizes to government agencies whose employees rack up the most downloads. And small businesses, eager to jumpstart the economy, have given freebies to customers: A mall offers a box of chocolates to visitors who download the app.
Challenges
But more importantly, did the app work? Despite a successful launch, Guam’s response to covid-19 has faced great challenges overall. Many people, especially those from ethnic minority groups who came to Guam from other Pacific islands, live in multigenerational and overcrowded housing, often with limited access to medical care and even basic hygiene tools like sewers. municipal. The health department recently launched door-to-door testing in these neighborhoods and found positivity rates as high as 29%.
In early April, the governor’s office predicted that the virus could kill 3000 people—Almost 2% of the island’s population— over the next five months. This terrible prediction has not yet come true. From Monday, November 30 112 people they would have died of covid on the island. Overall, the territory’s trajectory has been typical of the United States: cases have been low for most of the summer, before increasing steadily in the fall and recovering in early November.
While a large proportion of residents have downloaded the app, a major challenge has been getting people to download positive test results. This is in part because people are often in shock when they hear about their diagnosis, according to Janela Carrera, an official in the health department.
Contact trackers call anyone who tests positive, and part of their script is recommending people download their positive result – this is how the app knows how to send (anonymous) exposure notifications to people. people who have been close to each other. . But that first call can be extremely stressful, and now is not a good time to suggest trying a new app or going through the process of entering a special digital code that starts the notification chain.
“Especially if they are symptomatic, they may feel like, ‘OMG, I might not be recovering’ or ‘I could infect other people in my house.’ Then [contact tracers] follow up with them a few days later, once they’ve had a chance to collect, then offer the code, ”Carrera explains.
However, it is clear that some people download the codes. “Some colleagues said to me: ‘Janela, my God, I got a notification!’” Says Carrera. Ocampo himself received one in October and was quarantined for 14 days.
This is reinforced by the fact that when public health workers do their door-to-door testing, they provide information on how to download the app. At the same time, other strategies, often shared through multilingual public service announcements on local radio, may be more effective for people in these communities, who often only use smartphones for texting. , according to Muñoz.
Guam faces another very common challenge around the world. It is difficult to know exactly what the effect of the application is, says Sam Zimmermann, technical director of PathCheck Foundation.
Zimmermann says, “Because Guam cares so much about the privacy and security of their systems, their app doesn’t have any kind of analysis or logging,” as if users were actually learning how the app works after the download or if they are careful. if they receive an exposure notification.
Yet while the team launched the app in hopes of achieving a 60% download rate based on an early mathematical model, there is now evidence that even a much smaller portion of the population that has it. uses can have a positive impact.
Muñoz, for his part, hopes the app will help ease the pressure from health officials who carry out labor-intensive outreach activities such as door-to-door testing.
“Manual contact trackers have a very difficult job. They can’t follow everyone who tests positive, ”Muñoz says. “Any small percentage helps.”
This story is part of the Pandemic Technology Project, supported by the Rockefeller Foundation.
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