Massively Expanding Testing: A Late and Still Very Inadequate BeginningPosted: April 16, 2020
For both social and economic reasons, people will soon begin to re-congregate even while awaiting the availability of a vaccine that itself may be less than foolproof. In fact, if estimates of a 15 or 20 percent unemployment rate prove correct, that means that still over 80 percent of workers have remained employed, often in groups and factories that provide the vital goods and services we need. Meanwhile, families increasingly will do what they have to do: gather to solve such problems as child and elderly care, food purchases, and shared rent. These social and economic demands increasingly will force physical contacts to expand.
Clearly, “bending the curve” on the rate of new infections and demands on hospitals only begins to deal with the crisis. Health experts tell us we seem far from a science-based plan for reopening the country. Nonetheless, individual needs and demands for increased production of vital goods and services made scarce by trade disruptions will lead to further opening up social and economic life even in absence of vital information on the risks entailed.
Accordingly, the debate over testing, its funding and expansion, has itself started to ramp up, but it must move way beyond considering what a medical model centered in the doctor’s office or hospital requires, what South Korea or China achieved when, even by late March, they had tested far less than one percent of the population, and even beyond the phase of extensive testing and surveillance, as suggested separately in roadmaps by Ezekiel Emanuel and Mark McClellan and colleagues.
Instead, I’m referring to the need to reinforce a top-down medical model with a bottom-up economic model that informs the billions of associational decisions that are being made daily by households and businesses with whatever information they have on who is infected, recovered, immune, or currently virus-free. Even while awaiting a vaccine, or even after a far-from-foolproof one is developed, very broad expansion of testing can inform almost all of us better on how to limit the extraordinary social and economic costs of isolation.
Policymakers are starting to pay attention to his issue. Recent late-in-the game efforts include Medicare’s recent decision to double to $100 what it pays for a test derived through high throughput technologies and a $30 billion testing subsidy that Congress is only now considering after already passing a $2 trillion plus package. Yet even these only touch on what is required to ramp up production, distribution, information networks, potential patent purchases, and, perhaps, use of wartime production powers.
To see what I mean, suppose ideally that testing was widely and easily available for everyone and on a frequent basis regardless of symptoms. Think of some of the inventive ways that individuals and businesses might make use of knowledge that they, along with family members, coworkers, and other parties, are free from the virus or had developed immunities to it.
An immediate gain, of course, will be the reduced stress and anxiety of hundreds of millions.
At the same time, social isolation can be reduced by making it much easier to move from individual isolation to what I will call “group isolation.” Access to testing with quick results could enable a tested child to take a tested elderly parent out of the nursing home. Extended families could more easily visit among themselves to deal with family needs. Childcare can more safely be employed for millions who have to work. Families could more readily combine to care for children, the impaired, and those most isolated.
Poorer and newly immigrant families for millennia have dealt with their economic needs by clustering together, and, indeed, many do so now—one likely reason, along with the need to work, for their higher death rates. Lack of adequate testing deters these social opportunities and reduces avoidable costs where clustering already occurs.
If serology or other testing gave us a better handle on who had immunity and the extent of that immunity, including many who didn’t even know they had been infected, these individuals could make a better risk assessment of whether to return to work or volunteer to fill in for economic functions increasingly found vital.
On-site work becomes a more extensive and safer opportunity. As already noted, employment rates tell us that most businesses still operate. Workers live together at New York utilities and dorm together in Chinese factories. AngelSoft brags that its factories hum day and night, partly to deal with our fetish on hoarding toilet paper.
Such practices could be made more extensive more quickly, as well as safer. Creative restaurant entrepreneurs might find new ways to keep their staffs safely employed, perhaps rotated in combined work and living arrangements for, say, weeks on and then weeks off. The temporary closing of factories, such as has occurred with meat-processing plants, would more easily be avoided. Protections would expand for truck and bus drivers delivering the goods and transportation that people need, grocery clerks selling needed food, equipment repair experts who keep homes functioning, health scientists working around the clock, and so many others. With safer conditions, these workers might also be less likely to quit or go on strike.
Don’t get me wrong, my focus is long-term. Even with recent improvements in testing, doctors still have to go through bureaucratic hurdles to get tests and, when made, still have to wait for results. While people without major symptoms today should be discouraged from competing for scarce test kits, the opposite should hold as near in the future as possible.
The focus up to now has been on limiting numbers initially affected and flattening the curve so that our hospitals are not overwhelmed. But the threats to both our health and the economy in all likelihood will remain for months or years, depending partly upon when a vaccine is developed, how fast it can be manufactured and deployed, and the continuing power of the virus to spread. Recognizing these extraordinary costs and the possible world-wide need for billions of vaccines, Bill Gates recently suggested that we start now to gear up manufacturing facilities even for promising vaccines that might not prove efficacious.
I’m suggesting similarly that now is the time to ramp very large interventions for testing. Its invention and improvements don’t seem to face the same hurdles as does a vaccine. Abbott Laboratories alone claims that it expects monthly to produce 5 million point-of-care tests that can detect the novel coronavirus in as little as five minutes. Yet, with a U.S. population of about 330 million and a world population of 8 billion, we’re still talking about allocating a very scarce resource. Mologic works on developing a one-dollar, 10-minute home test, primarily for Africa, that would not require labs, electricity or sourcing supplies from global manufacturers.
Invention is only part of the battle. Government must immediately plan for and finance much broader production and distribution systems for whatever might come along. The health system will need to adapt to new, as not-yet-fully-understood, opportunities, while supporting testing and information systems that don’t rely excessively on doctors, nurses or other trained officials. Their numbers simply are too small to provide one-on-one testing, much less advice, to tens or hundreds of millions of people regularly being tested. Lesser developed nations with limited health providers and weak supply systems already are forced to think this way. And the U.S. recovery depends in no small part on recovery abroad, as well.
There is no doubt that richer firms and organizations will not await government actions. What tests Stanford and Apple are now providing for local first responders, you can be sure at some point they will be giving to their own workers and staffs, even if they individually have to expand or create their own laboratory facilities or use less reliable tests when better ones are too scarce. But only the government can achieve the breadth and scale required for millions of households and businesses.
Obviously, the adaptations themselves will depend upon the types, qualities, and levels of testing made possible, especially should at-home or on-site tests be able to provide timely results.
As Bill Gates discussed with vaccines, multiple systems likely will be required, should periodic improvements make obsolete more expensive, less reliable, tests. The imperfection of tests and their processing requires dealing with liability laws that could slow down improvements and recovery itself. Patent law must also be tackled, and government must decide whether, as Burt Weisbrod from Northwestern University suggested long before this outbreak, whether up-front government purchases of patents will be more efficient than depending upon firm decisions over production, distribution, and price. As with ventilators, the Defense Production Act may need to be invoked.
A simple back-of-the-envelope calculation suggests that if at peak the virus reduces total U.S. economic activity by one quarter, that adds up to about $100 billion less in U.S. output and income per week. Double that amount to account for foregone nonmarket production and the unmeasured cost of social isolation and its attendant health costs. The cost of a vastly expanded system of testing seems minor by comparison to advancing the recovery phase by even one week.
So, yes, first focus on expanding testing so that the healthcare system can readily test those with symptoms and then track down and isolate those with whom they have had contact. That discussion is already underway. But recognize, finance and organize now for how a greatly expanded system can further inform the billions of social and economic associational decisions that households and businesses will and often must make every day.