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A health care worker conducts a Covid-19 test at a drive-through testing facility at George Washington University in Washington, DC, on May 5.
Caroline Brehman/CQ-Roll Call, Inc/Getty Images

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Every conversation about reopening should be about testing

The US still needs to scale up coronavirus testing.

The conversation about when states should start to reopen their economies is growing louder and louder — with President Donald Trump and some governors suggesting it’s time to relax social distancing measures implemented in response to the coronavirus pandemic.

But many of those conversations are missing the point.

According to public health experts, the conversations should first and foremost focus on Covid-19 testing. Until the US and individual states scale up their testing capabilities, they shouldn’t even start talking about the prospect of reopening their economies.

“There’s this really big focus from a lot of governors and leadership on ‘reopening the country,’ but not emphasizing what they’re doing to make testing happen,” Saskia Popescu, an infectious disease epidemiologist, told me. “We can’t talk about reopening until we have a strategy for [testing and tracing].”

It’s been said thousands of times throughout the crisis, but it bears repeating: Testing is a crucial component to getting control over the pandemic. When paired with contact tracing, testing lets officials track the scale of the outbreak, isolate the sick, quarantine those who the sick came in contact with, and deploy community-wide efforts as necessary.

In fact, scaling up testing is part of the reason we’re social distancing now. The idea is that shutting down large parts of the US is effectively a pause button — one that buys the country time, while flattening the curve, to build up health care and testing capacity.

“The whole point of this social distancing is to buy us time to build up capacity to do the types of public health interventions we know work,” Natalie Dean, a biostatistics professor at the University of Florida, told me. “If we’re not using this time to scale up testing to the level that we need it to be … we don’t have an exit strategy. And then when we lift things, we’re no better equipped than we were before.”

America, however, remains far from where it needs to be on testing. Experts say the US needs 500,000 tests a day, on the low end, to tens of millions, on the high end, to fully control the coronavirus outbreak. Based on the COVID Tracking Project, the US has averaged about 260,000 tests a day — a little more than half the minimum needed — over the first week of May.

A chart showing the number of coronavirus tests reported in the US each day.

That testing is still a problem, months into the outbreak, is baffling to many experts. In pandemic preparedness simulations she took part in before Covid-19, Popescu said, testing didn’t even come up as a potential problem. “We always assumed we would have widespread testing capabilities,” she said.

The issue continues to be supply shortages — for swabs, reagents, personal protective equipment, and other materials needed for tests — that make it impossible to scale up testing quickly enough. These kinds of issues require federal leadership to find and fix supply chain bottlenecks. But in recent weeks, the Trump administration has largely punted the problem to the states, reportedly even rejecting CDC guidelines for how to reopen safely.

In the absence of strong federal leadership, states seem to be following their own paths — pushing to reopen even as the data suggests they don’t have the number of tests to do so, at least safely. In the face of such obvious failures, many don’t seem interested in having conversations about the very issue that should guide their decisions to open back up.

We still don’t have enough tests

The numbers are pretty clear: America is, by and large, not ready to safely reopen. This is true not just at the national level, but for individual states, too.

An analysis in the New York Times by Keith Collins and Lauren Leatherby on May 7 was particularly instructive: It found that the majority of the 30 states moving to reopen don’t meet the criteria set out by the White House to do so, even though that criteria was quickly criticized by experts as being too vague and lenient.

“In more than half of states easing restrictions, case counts are trending upward, positive test results are rising, or both, raising concerns among public health experts,” Collins and Leatherby wrote.

By more stringent — and responsible — criteria, the states look even worse. The Times has translated the 500,000-tests-a-day minimum supported by experts to about 152 tests per 100,000 people. Only two states, Rhode Island and North Dakota, meet this standard. And, again, this is the minimum; some experts argue the US needs multiple times that number of tests.

Another metric used by experts is the positive rate. This measures what percent of people test positive for the coronavirus among all tests done. If the positive rate is high, it’s likely that not enough people are being tested, since it suggests only people with a high chance of infection are being tested, potentially missing a lot of people without significant symptoms. The maximum acceptable positive rate is typically 10 percent, experts told the Times.

The majority of states pushing to reopen have a positive rate above 10 percent. And in a handful of cases, like in Oklahoma and Georgia, the positive rate has recently increased.

In short: The vast majority of states don’t have the testing capacity to reopen, even as most talk about easing social distancing.

More tests are needed to safely reopen

Testing is how other countries, like South Korea and Germany, have managed to control their outbreaks and started to reopen their economies. By pairing testing with aggressive contact tracing, they have managed to, in the terms of some epidemiologists, detect and put out embers before they turn into wildfires.

America is simply not there yet. The country continues to be mired in a variety of supply problems, depending on the time and place, that inhibit testing. Some places don’t have the swabs to collect testing samples. Some don’t have the personal protective equipment to let staff collect and transport samples. Some don’t have the vials to store samples. Some don’t have the reagents to run the tests. Some don’t have the platforms for specific kinds of tests.

Labs, other health care facilities, and local and state governments can’t fix these issues by themselves. One way to think about this: If the new bottleneck is a swab factory in Maine, there’s simply nothing Maryland can do about it. The federal government is the only entity in the US capable of tracking, coordinating, and fixing these kinds of supply issues around the country.

“This is supply chain 101. This is operations 101,” Nada Sanders, a supply chain management expert at Northeastern University, told me. “It’s so simple. And it’s just not happening.”

The Trump administration, instead, has seemingly surrendered its role here. In late April, the administration put out a testing plan that placed the responsibility of finding and solving problems on the states and the private sector, arguing that the federal government would only play a supplementary role with “guidelines,” “strategic direction,” and “technical assistance,” and act only as a “supplier of last resort.”

Beyond testing, a report from the Johns Hopkins Center for Health Security and the Association of State and Territorial Health estimated the US will need to hire 100,000 contact tracers — far above what states and federal officials have said they’re hiring.

It’s not that we don’t know what the problems are here. It’s that federal leadership simply isn’t acting quickly or aggressively enough to fix them.

That’s led some experts to argue that this is not just a public health debacle but also a failure of America’s political system. “This is a disease that does not just test your health system,” Jeremy Konyndyk, an expert in disease outbreak preparedness at the Center for Global Development, told me. “It tests your political system. It tests the quality and competence of your governance.”

To solve this, America’s political leadership — at the local and state levels, but particularly the federal level — has to acknowledge a simple fact: Any discussion about reopening has to focus on testing. Only once that happens can these problems actually get fixed, and only then could the country more seriously start talking about easing social distancing without putting millions of Americans in danger.


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