Underneath our debate about practicalities and problem-solving is a debate about ideas. Three key ones are at stake.
The first idea at stake is what diagnostic tests should be for.
Should tests be used only therapeutically to diagnose and treat the sick, or should they be used to control the disease? Therapeutic usage helps make sure we can distinguish, for instance, other kinds of respiratory infections from covid-19, which requires a higher level of infection control. You use different treatment protocols for different kinds of respiratory illnesses, and testing helps allocate resources appropriately and control infection in medical contexts. The current Centers for Disease Control and Prevention guidance that tests be used only for symptomatic people is focused on therapeutic usage. We currently have enough tests for that therapeutic purpose.
But can tests also help control the disease outside of the clinical setting? Yes, just as masks can. Some 20 to 40 percent of people infected with the novel coronavirus are asymptomatic. They are significant disease “vectors.” To control the disease without mass stay-at-home orders, you need to be able to test broadly enough to find those asymptomatic people and to find their contacts and test those people, too. Finding all the asymptomatic covid-19 people and having them isolate, with strong social supports, is the best available tool for controlling covid-19 that we are not currently using.
This issue is exactly like the masks issue, in fact. Yes, when we had a small supply, we needed to limit their use to the clinical setting. But at the same time, we needed to massively scale up supply so that everyone could use masks, because they help keep those who don’t know they’re positive from spreading the disease and they help all of us touch our faces less. It’s the same with tests. While we needed to ration at first, by now we should be aggressively scaling up.
Here’s the second core idea being debated.
Which kind of toolkit for control and suppression of disease do we want? A toolkit in which collective stay-at-home orders are a standard and regularly used tool, or one in which they are the absolutely last-stage emergency tool only, and the goal is to never need to use them? If we want the former toolkit, we currently have enough tests. If we want the latter, where we use testing, tracing and supported isolation (TTSI) to find and control the disease, we need many more tests than we have. The former toolkit points us toward current levels of 1 million tests a week. The TTSI toolkit approach points us toward much higher levels, more like 5 million a day, according to research for the report “Roadmap to Pandemic Resilience.”
Here’s the third core idea being debated. Should we hope for the best and plan for the best, or hope for the best and plan for the worst?
The best-case scenario is one in which by the middle of June we have new therapeutics that so significantly reduce the severity of disease and improve its treatability that we no longer really need to worry about how much the disease spreads. And we are seeing good progress. It is within the realm of the possible that we could open up now, without broad testing, and that just when we see cases start to rise again, the therapies will come online and the next wave of the disease will be experienced very differently from the first one.
But should we plan for that pathway? I believe not. That policy has sufficient levels of uncertainty that it makes it impossible for businesses and schools to plan effectively. Would we still be open come fall? That’s the burning question. For the economy to roar back to life, businesses need to know that we will reopen and stay open. For that, we need a broad program of TTSI. No country that has controlled the disease and stayed open has done it without TTSI.
I want to open as soon as possible, and I want to stay open. For that reason, I want testing, tracing and supported isolation. We have the capacity to deliver tests at the scale needed for TTSI. We’re can-do America, and we can deliver. I say we go for it.