What Are We Trying to Accomplish with Testing?

We’ve heard a lot of conflicting and confusing information in recent days about testing. Public officials in different areas have announced that the time for testing has passed and in some areas efforts at mass testing – drive through testing, and such – is being scaled back. This comes after a couple weeks when rapidly expanding testing was the central focus of preparedness, containment and mitigation efforts. On Sunday longtime TPM Reader BB wrote in that he “can’t quite get my head around what we think wider testing is going to accomplish” and then listed a series of critical reasons why officials in hot zones are now in some cases moving to limit testing.

Let me try to answer this by ‘answer’ here I am simply trying to synthesize as best I can the thinking and arguments of public health experts and clinicians whose reports and commentary I am following as closely as I can.

The first thing is to face the severity of the crisis in which we have suddenly found ourselves. It’s not just the toll of suffering and death but acute shortages that shatter whatever smug confidence we have in our wealth, preparation and and general ‘bestness’ versus the rest of the world. Health care workers are now treating patients with a mix of improvised and reused or insufficient protective gear (so-called PPE – gowns, masks, face shields, gloves etc.), actions that in any other circumstances would be considered grossly negligent. This not only puts the health care workers at risk individually it risks a cascading failure in which overwhelmed hospitals start losing health care workers to the disease as the scale of incoming patients mounts.

Testing also requires health care workers and the same protective gear, both of which the hospitals are running out of. With the technology bottleneck in testing finally freeing up we are facing a human bottleneck and the people who take the samples and the gear that protects them are in too short a supply.

We are currently in a situation in which our hospital workers are already running out of protective gear and even running out of health care workers and we are simultaneously diverting both to mass-testing. It is a bleak zero-sum situation and at calmer moments in the future we will have to reflect on how we collectively allowed ourselves to come to such a pass.

But that’s the gist: We have arrived at a situation in which critical care for the gravely ill and dying is directly at odds with testing at scale. The problem is there’s simply no way to stabilize the situation and get through the coming months without testing at scale or more specifically testing for the purposes of surveillance.

Let’s start with a few assumptions to frame the questions.

There is little reason to believe we will have game-changing medical interventions in hand before early 2021 – vaccines or effective medications. We may get lucky with therapies and at least the standard of care is likely to evolve and improve. But we must assume we’re on our own in terms of medicinal interventions for that long. Yet there’s no way for the country to remain in the present state of total lockdown for a year or eighteen months. So what do we do? The answer has to be that we stay in something like radical lockdown until the country can bring the immediate outbreak under control or ramp it down dramatically.

We know that this is possible. We’ve seen it happen in China. Right now the very blunt weapon of radical societal lockdown is the only way we know how to get back ahead of the curve. Some significant period of that, likely measured in weeks, will be necessary simply to get the spread of the disease under any kind of control. And by control here we don’t mean it’s over. We mean getting exponential growth back down to incremental growth.

This gets us to another issue about testing. We need to be thinking about clinical testing, which is useful to guide the course of treatment for individuals and, surveillance and public health testing which is necessary for the broader containment and control of the epidemic. Because of the severity of the situation in our hospitals, shortages of PPE and people, we’re basically forced to place almost all our emphasis on the former category. Once we exert some level of control over the epidemic we’ll be able to move more focusing to broad testing.

The order of events will have to be something like this. Everybody but essential personnel goes into full lockdown because during explosive spread and without effective testing at scale that is the only way to reduce the spread. Simultaneously, support hospitals and health care workers caring for the wave of critically ill patients flooding into hospitals. Hopefully the first effort (radical social distancing) will eventually end the immediate crisis in the second (the wave of critically ill people pouring into hospitals).

From there broader testing will become critical because only with testing at scale and aggressive contact tracing and quarantines will we be able to get to a new normal that will be sustainable into next year when hopefully you have medical interventions which can actually end the crisis. Only surveillance testing will allow us to fine tune the economy-crushing blunt instrument of radical lockdown. Testing here means not only testing for infection, as we’re already doing, but serological testing which tells you who has already been infected and (most likely) is now immune. Researchers are still trying to confirm how immune you are and for how long. But people who are immune will obviously be key players in providing assistance in a semi-social distanced world. All of this is necessary to produce the data to monitor effectively.

We can’t stay in total lockdown for 18 months. But when we can ease up somewhat, how we can ease up and to guard against a second outbreak when we’re semi-eased up – all of that will come down to testing for surveillance, monitoring, contact tracing and quarantines.

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