Note To Country: Don’t Fly Into a Mountain

NEW YORK, NEW YORK - MAY 06: Refrigerated trucks functioning as temporary morgues are seen at the South Brooklyn Marine Terminal on May 06, 2020 in the Brooklyn borough of New York City. New York City's Medical Exami... NEW YORK, NEW YORK - MAY 06: Refrigerated trucks functioning as temporary morgues are seen at the South Brooklyn Marine Terminal on May 06, 2020 in the Brooklyn borough of New York City. New York City's Medical Examiner are now operating a long-term disaster morgue at Brooklyn's 39th Street Pier, where human remains will be kept inside freezer trucks, in an effort to provide relief to funeral directors overwhelmed from the COVID-19 crisis. (Photo by Justin Heiman/Getty Images) MORE LESS
May 13, 2020 4:40 p.m.

As I noted below, we are now getting sufficiently dense data on the genetic lineages of COVID19 to map its introduction and spread within the United States – both in time and geography. The preliminary evidence suggests the epidemic in New York City began after COVID was introduced from Europe in mid-February. Perhaps there were isolated introductions earlier. Given the scale of international travel in and out of the city it seems hard to imagine there wasn’t. But it was this mid-February introduction that took root and exploded, ultimately infecting more than 1.5 million city residents and killing at least 20,000 people. Now that this virological, genomic history is coming into clearer view it is time to consider an alternative history of the epidemic, one in which the US fielded tests two or three weeks before the point of introduction to what would become the epicenter of the US epidemic.

Let’s review the history.

The genetic code of the virus that causes COVID19 was published in early January. On January 16th German researchers published the protocol for the first COVID19 test. Five days later, on January 21st, the CDC announced that it had confirmed the first case of COVID in the United States with its own test.

Tests were available, createable and produced in the third week of January. The CDC had one. But from there things quickly broke down. The test produced by the CDC and sent out to the states had a manufacturing flaw and couldn’t be used. State public health labs then had to send samples for testing at the CDC in Atlanta. This meant that testing capacity was radically constrained in the US basically from the start.

As we discussed back on March 6th, though, the issue seems to have been less technical than organizational and bureaucratic. There was a technical problem with the CDC test. But the US has vast additional capacity – in the private sector, in state public health labs and academic institutions – to create and manufacture tests. The issue was that the FDA, which has authority over approving tests, didn’t approve other efforts to move forward until early March. At a basic level the problem was one of communications and leadership. Both agencies are housed within the Department of Health and Human Services. Neither effectively communicated with the other or others in the Department about the critical, time-sensitive nature of the problem or the role they each had to play in resolving it.

What remains unclear to me is how much the highly restrictive criteria for testing – themselves seemingly devised to grapple with the shortage of tests – became a reason for not moving quickly to find other sources of tests. It is true that as long as testing was restricted to people who were symptomatic for COVID and had a recent travel history to China, there were plenty of tests to go around. Through February federal officials consistently said that there was no need to test people who didn’t meet this criteria. Only late in the month did those officials shift to the real or at least more fundamental issue, which was that there weren’t enough tests for testing on any wider basis.

Regardless of the answers to those questions, the key point is that the problems with the original CDC test was a recoverable problem. The administration simply spent more than a month not recovering from it. That was fundamentally a failure of leadership on the part of appointees at CDC, FDA, HHS and ultimately the White House.

Here we must return to our alternative history, one in which the US began testing for COVID in late January or at the latest early February. In an ideal world the US might have started broad, random surveillance testing to find the first signs of an outbreak. More mundane but also effective would have been testing every American who showed up in an emergency room with signs of a respiratory infection. That would have detected the first signs of the outbreak early in New York and the rest of the country.

As it was, public health officials were reduced to monitoring the existing national flu surveillance network which monitors influence-like illness (ILI). But as long as the flu season was raging, as it was in January and February, it would take a big spike for a COVID signal to break through. As late as March 7th, three weeks into the outbreak in New York City, public health experts had to monitor ili data showing an out-of-season spike in cases and wonder if it could be the first sign of an outbreak in the city.

That was March 7th. It was ten days until the city’s schools shuttered, two and a half weeks until the city fully went into lockdown. That was almost six weeks after the outbreak began and at least three weeks after the scale of the outbreak would have been fully detectable with ample testing capacity.

This isn’t Monday morning quarterbacking. Countless public health officials, researchers, average people who didn’t want to get COVID were raising the alarm through February. By the latter part of the month public health laboratories were alternatively begging and demanding the FDA allow them to field their own tests. None of these people knew the scale of the outbreak. There was no way they could. There was effectively no testing. But the fact it was exploding in Europe as well as Asia made it the height of wishful thinking to imagine it wasn’t already happening unseen or soon to happen in the US.

Entering a major global pandemic with no testing is like flying in instruments-only conditions with no instruments. Are you cruising along at 30,000 or flying into a mountain? New York City was flying into a mountain. We could have known but we didn’t. Losing six weeks was fatal.

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