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More, better, and faster testing might have averted the worst of what America faced in 2020.
The coronavirus pandemic may be in its final stage in the U.S. But it will not be the last pandemic of the 21st century.
Since the turn of the century, SARS-CoV-2 is already the second virus to create a pandemic (the first was the H1N1 influenza in 2009) and the third coronavirus outbreak, following the first SARS crisis in 2003 and the emergence of Middle Eastern Respiratory Syndrome, also known as MERS, in 2012.
If the U.S. can expect roughly one global plague every 10 years, it will have to do better than it did over the past 12 months, when it shut down much of the economy to save lives but lost more than 500,000 souls anyway. In the past few weeks, I asked several scientists, epidemiologists, and other experts to tell me what they considered the foundational failure, or “original sin,” of our COVID-19 response. Was it the hemming and hawing over masks? The overly constrictive lockdowns in places that didn’t yet require them, followed by a reluctance to re-impose them when they became necessary? The delusional denials from the Trump administration? All received a mention. But to my surprise, one thing stood out above everything else: tests.
“I don’t think there’s any question that America’s original sin was not having a broadly available test by the time COVID-19 was here,” said Eric Topol, a cardiologist and the founder and director of the Scripps Research facility. “It’s atrocious, egregious, and grotesque. We’re still living with the fallout of not having enough tests. It’s the original sin that has become our daily tragedy.”
Natalie Dean, an epidemiology professor at the University of Florida, agreed. “To me, it all starts with the lack of early testing,” she said. “The process was so bungled, it took so long to set up any kind of testing capacity, and by the time we could properly test people, there was already widespread community transmission.”
Alex Tabarrok, an economist at George Mason University, said the same thing: “If the U.S. government had done everything right with testing, we could still have ended up being screwed. But in any alternative universe in which we succeed, our success would begin with testing.”
Mask ordinances and social distancing (and, now, vaccines) have almost surely saved many thousands of lives. But before any of these remedies came about, America’s inability to track the virus allowed it to establish a base of infection and an exponential trajectory. The testing fiasco was uniquely responsible for launching the U.S. into the national nightmare of an unchecked explosion in cases. More than any other policy failure, it turned what might have been an acute national horror into a tragedy that took more lives than either world war.
America’s testing failure was not a single missed opportunity or bad decision. It was a cavalcade of unpreparedness and hubris that doomed the U.S. to disaster. The federal government neither quickly developed its own working test nor quickly approved effective tests developed by American scientists outside government; it declined to request a diagnostic test from the World Health Organization; it ignored the benefits of cheap “rapid tests”; and it failed to communicate to the public how mass testing would maintain a shred of normalcy by making visible a pathogen whose spooky invisibility had triggered the shutdown of the economy.
Eric topol divides his blame for America’s original testing sin among three institutions: the White House, the CDC, and the FDA.
Donald Trump’s culpability is so obvious, elaborating on the matter may seem almost gauche. The ex-president denied and downplayed the virus; confidently—but incorrectly—predicted its sudden disappearance; and falsely claimed that “anybody that wants a test can get a test” on March 6. (On that day, the U.S. performed only about 1,500 total tests, or roughly four tests for each metropolitan statistical area.) Trump was wrong about COVID-19 in almost every possible way that a person can be wrong about a thing, and he burdened the entire public-health system with mercurial demands for easy fixes and junk science.
But the U.S. failed in ways that extend beyond Trump’s orbit. “The CDC and [then-Director] Robert Redfield deserve as much blame as anybody,” Topol said. On January 10, 2020, several weeks after the world learned that an unusually contagious virus had shut down the Chinese city of Wuhan, the CDC insisted in calls to local and state public-health officials that it would soon have working tests to distribute throughout the country. Three weeks later, the first kits arrived by FedEx in Manhattan laboratories. They didn’t work—at all. “Oh, shit,” is how Jennifer Rakeman, the director of the New York City Public Health Department’s lab, described her reaction. “What are we going to do now?”
Even as U.S. scientists were developing in-house tests to diagnose coronavirus infections, the FDA was dragging its feet on approval. In January, Alex Greninger, a virologist at the University of Washington, designed a more effective diagnostic test than the CDC. But federal regulators put him through the wringer—requiring an online application that would take 100 hours to complete; then requesting a hard copy of that application; then insisting that he obtain samples of other coronaviruses, which the CDC had restricted access to. By the time Greninger’s test was approved, the calendar had turned to March and hundreds of thousands of Americans had probably already been infected.
America’s testing capacity eventually rose to more than 2 million per day. But some observers believe that wasn’t nearly enough. The economist Paul Romer argued that the U.S. needed at least 10 times that—20 million to 30 million daily tests—to open up more of the economy safely in 2020. The best way to hit that figure would have been for the U.S. government to accelerate the production of cheap, rapid antigen paper tests, which could have been distributed en masse directly to residents.
The Harvard epidemiologist Michael Mina has excoriated America’s inability to scale up the development of these rapid tests, which can deliver results in minutes instead of days (albeit with less precision for asymptomatic carriers than the gold-standard PCR tests). “We could’ve at least tried, back in May, to get these rapid tests out,” Mina told New York magazine last month. “We didn’t do it in May. We didn’t do it in August, November, December. We still haven’t done it.”
Other countries adopted an aggressive testing strategy from the start. South Korea knew from experience the value of tracking infections as fast as possible, having grappled with the first SARS, H1N1, and MERS in the previous two decades. A nation one-sixth the size of the U.S., South Korea nonetheless had tested 200,000 people before the U.S. had tested 20,000 of its citizens.
America’s testing fiasco was the seed from which so many other tactical blunders, extreme policy responses, and public-health misunderstandings bloomed. An invisible virus that escapes most detection required that city and state leaders treat all citizens as equally likely to be carriers of the virus. That led to the closure of schools; cancellations of weddings; prohibitions on funerals; and the shutdown of the entire leisure, hospitality, and indoor-retail economy. Widespread tests would have identified carriers with greater speed, making school closures unnecessary and travel less risky. With too few tests to go around, we rationed them for the most severe cases, and let silent spreaders go mostly unidentified, Natalie Dean told me. “We had overly narrow restrictions on who could be tested for weeks, while there was widespread community transmission,” she said. With more tests, we would have learned more, faster about this disease—including that it was circulating through asymptomatic infection and super-spreaders. That would have suggested an airborne virus, which would have strengthened the case for masks in March, when even public-health leaders like Anthony Fauci were wavering on everyday mask use. With more and faster tests, the U.S. would have benefited, at least a little bit, in almost every capacity: We would have had greater and faster epidemiological knowledge, less stringent lockdowns, a more open economy, and fewer overall deaths.
Perhaps you’re not convinced. Perhaps you think testing wouldn’t have made a big difference. If that’s how you feel, consider this hypothetical. Imagine a parallel universe where Americans were tested massively, constantly, without care for cost, while those who tested negative continued more or less about their daily life.
In fact, that parallel universe exists. It’s the National Football League.
When the NFL season started, in September, I was deeply pessimistic that it would end in anything other than mass infection and cancellation. This is, after all, a league with a deplorable public-health record, whose players spend large amounts of time in indoor facilities and locker rooms, when they’re not smashing their helmeted faces into one another on the field. But somehow, the NFL played all of its 256 games with no coronavirus-related deaths reported among its thousands of players and employees.
How did the league do this, even as the U.S. faced a surge in the winter? After an October outbreak, the NFL moved to daily testing of all its players and instituted new restrictions on player behavior and stricter rules on ventilation and social distancing. The league also used electronic tracking bracelets to trace close contacts of people who tested positive. Throughout the season, the NFL spent about $100 million on more than 900,000 tests performed on more than 11,000 players and staff members. In January, the CDC published an analysis of the league that concluded, “Daily testing allowed early, albeit not immediate, identification of infection,” enabling the league to play the game safely.
You could write off the NFL’s season as the idiosyncratic achievement of a greedy sport with nearly unlimited resources. But I can think of another self-interested institution with nearly unlimited resources: It’s the government of a country with a $20 trillion economy and full control over its own currency. Unlike the NFL, though, the U.S. never made mass testing its institutional priority.
“The NFL was almost like a Korea within the United States,” Alex Tabarrok told me. “And it’s not just the NFL. Many universities have done a fabulous job, like Cornell. They have followed the Korea example, which is repeated testing of students combined with quick isolation in campus dorms. Mass testing is a policy that works in practice, and it works in theory. It’s crazy to me that we didn’t try it.” Tabarrok said we can’t be sure that a Korean or NFL-style approach to national testing would have guaranteed Korean or NFL-style outcomes. After all, that would have meant averting about 500,000 deaths. Rather, he said, comprehensive early testing was our best shot at reducing deaths and getting back to normal faster.
At this moment in America, deaths and hospitalizations are plunging as the U.S. vaccinates millions of people a week while tens of millions more retain some form of immunity from previous infections. The basis of vaccination is immunological memory—the immune system’s ability to recognize and respond to pathogens that would otherwise ransack our bodies.
Just as important as immunological memory is institutional memory. A nation can learn from its mistakes: South Korea did better against COVID-19 in part thanks to a national familiarity with airborne viruses. The U.S. can use the brutal experience of 2020 to recognize and respond with greater speed and precision to the next dangerous pathogen. In this pandemic, testing was America’s original sin. In the next pandemic, and there will be a next pandemic, it can be our first step.
Derek Thompson is a staff writer at The Atlantic.