The Real Issues Concerning COVID-19—Part VI, About The Drumbeat For COVID-19 Testing

On May 15, 2020, Russ Roberts published another splendid podcast interview of Paul Romer, “economist and policy entrepreneur, is a co-recipient of the 2018 Nobel Prize in Economics Sciences and University Professor in Economics at NYU,” and more.^[i] The podcast focused on several aspects of the COVID-19 pandemic. While I highly recommend that you listen to it, Romer adding his mallet to the drumbeat for widespread testing advocates is unhelpful.

Widespread testing (“testing”^[1]) was among the podcast’s topics. According to Romer, testing is the key to getting people comfortable enough to actively engage in commerce—which both Roberts and Romer believe to be of paramount importance. Enough people being that comfortable is essential to any semblance of a recovery. His “case” for how and why testing would accomplish that goal was this:

“The idea with testing, though, is that if there’s some information we don’t have, what we’d like to know is whose infectious right now. If we knew that information, what we could do is say we’re going to isolate those people for a short period of time, a few weeks, and we can then suppress the virus without interfering with anybody else’s daily lives.”

Note, however, that “case” does not identify either how or why testing should or will cause people to be more comfortable.

Other advocates of testing offer different rationales:

Dr. Fauci: “The one thing we hopefully would have in place, and I believe we will have in place, is a much more robust system to be able to identify someone who’s infected, isolate them and then do contact tracing.”^[ii]

CDC: “CDC has a strategy for using antibody testing as part of surveillance efforts to better understand how much of the U.S. population has been infected with SARS-CoV-2 and how the virus is spreading through the population over time.”^[iii]

WHO: “identify, isolate and contact trace people with the disease,” “vital part of understanding the scale of the outbreak and how it is evolving” and “Effective testing and quarantine measures help ease the pressure on health services, which can quickly become overwhelmed as demand surges for respirators and other critical lifesaving equipment.”^[iv]

The Media: The media doesn’t even try to explain testing’s goal other than identifying hotspots (which happened without testing) or whether tracing could be effectively and acceptably implemented.^[v]

Those rationales aim to slow or stop the virus’ spread, i.e., “flatten the curve” or some unidentified way to permanently stop the virus from infecting people. They offer no insight as to how testing is a substitute for herd immunity to stop the pandemic. Tinkering with the timing of when the virus infects and kills is of great value only when hospitals are at risk of being overwhelmed. Otherwise, “If all we do is flatten the curve you don’t prevent deaths, it simply changes the date of their death,”^[vi] Time is not on the side of the especially vulnerable.^[vii] Rarely do people believe that fiddling while Rome burns is a good strategy—but here we are.

Let’s sort that out why testing and tracing are impractical and inapplicable to America.

One of the goals of testing is to enable “contact tracing,” i.e., find someone infected, identify everyone the infected person encountered, and whisk them all away to confinement. For sake of argument, let’s assume that the needed infrastructure (wireless surveillance, electronic notification systems, human catchers, detention centers, staff, and supply chains, courthouses to try habeas corpus cases, etc. and popular acceptance and adoption thereof) could be in place and running smoothly before the economy collapses. Is that the society in which we want to live? By forcing people to wear ankle bracelets and accept detention, S. Korea^[viii] pulled it off, as did China by forcibly removing people from homes and throwing them into coronavirus detention facilities.^[ix] Americans will not go there peaceably.

America tried a milder version of contact tracing. Here is what Romer said about that:

“…[America’s early attempts at contract tracing] partly colored by our experience, which was: the contact tracing system was the system we were using in January when this virus exploded, and it just completely failed. The people who say, ‘Okay, well contact tracing is going to work, give us a do-over,’ I don’t see the evidence that it’s going to be different if we do it again.”

Consider the practicality of widespread tracing. America’s population is about 325 million. People are spread across and between 35,000 cities and towns. Consider the following variables to be normalized in order to make sense of COVID-19 test results concerning how many people are infected; have become immune, seriously ill, and/or died:

What are the mixes of preexisting conditions, age, race, and abilities/willingness to follow protocols;
What protocols were established, when, and how aggressively; and
Which local politicians/officials were smart (the jury is still out on this) or dumb^[x] in their speeches and policies; and
What other variables play a role, e.g., temperature, humidity, and sunlight.

Each of these variables varies significantly from place to place. For example, compare COVID-19’s impact on the comparably sized populations of New York State and Florida. As of 5/17/2020, confirmed cases were 350,121, and 45,588 and deaths were 22,478, and 1973. The pandemic will have run its course before all the significant variables are identified and quantified sufficiently to be actionable.

Consequently, sampling must be done on a granular level to be useful. Collecting, analyzing, and applying that much data effectively is too massive to be accomplished. For example, if an average of 2000 tests were taken in 35,000 towns (forgetting about all the places in between), 70 million tests must be taken, shipped to labs, and analyzed per round to obtain the needed information. However, both diagnostic and serological tests are required. So, 140 million tests would be necessary. At 770,000 tests per day, America is leading the world in the number of tests per day. That is about 0.5% of the tests needed per round.

Consider how often test rounds are needed. Infected people typically shed high amounts of virus soon after infection and are asymptomatic for at least a few days. Irrespective of symptoms, people can be infectious for 10 days or more.^[xi] Let’s say a person goes to a testing facility, and three days later learns the test was negative. However, she may have become infected when she pulled the handle of the facility’s exit door. She would soon start shedding COVID-19 for many days while believing that she is virus-free. “To be safe,” she should get tested every day until she finally tests positive or the pandemic has run its course. People are already not showing up at test sites.^[xii] Because the virus can spread so quickly, the shelflife of test data is too short to be of much practical use—and getting close to enough tests everywhere is impossible.
For random sample testing to work, the people tested need to be representative of a larger group. Unlike randomly calling people, people who are willing and able to get tested could be very different from the larger group. People with no better way to earn money than getting tested will not be representative of the whole. People are already growing tired of being prevented from working, standing in breadlines, and staying at home. That sentiment is likely to increase until nonpharmaceutical interventions (“NPI”) stop. Will the data collected before a general abandonment of NPI be relevant when people have thrown off their masks and left the house? Will the people of all cities start abandoning NPI at the same time or the same rate? If not, most of the data collected will be of little practical use.

As noted above, tracing is for finding people to quarantine. However, as Dr. Jay Bhattacharya says, “That works fine if you have a small number of people who have been infected [which is not the case in the places where COVID-19 is a big problem] and… we’ve seen a very large number of people don’t have very many symptoms and, yet, can spread it, this kind of strategy will not work. It is doomed to fail. In fact, it’s going to be counterproductive to do a strategy like this… [if when they show positive, they will be quarantined] people will say they don’t want to be tested.”^[xiii] To be effective, quarantining must be enforced. Believing that forced testing/quarantining would work outside an authoritarian state is likely irrational, but certainly would produce unrepresentative/invalid test results.

Romer suggests that problems with quarantining might be solved by the government paying people to be quarantined. There are people on whom that might work and others on whom it will not, e.g., Jeff Bazos or the owner of a successful restaurant. The disparate results of randomly testing/quarantining poorer people is not a compelling strategy.

When pressed on how test results would be used, Romer said, “it’s premature to worry too much about what we do with that information.” He also made some of the “arguments” discussed above. However, they have the failings discussed above.

If there were a good argument for testing, surely Paul Romer and many other testing advocates would know what it is and would have already widely disseminated it. I’ve looked in vain for a sound argument.

On the off chance, a credible case for widespread testing exists, epidemiologists owe the public:

a clear presentation of the case,
an explanation as to why delaying the spread of the virus is not merely putting off the inevitable deaths that COVID-19 will cause.^[xiv] and
an identification of the point at which NPI will cause more illness and death than COVID-19 will (to say nothing of the lost dignity, security, thriving, and fun being destroyed by NPI).^[xv]

Absent that: The public should reject the claim that NPI easing must await widespread testing.

Let’s hope that people will soon realize the impractically and inapplicably of the testing “solution.”^[xvi]

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^[1] Unless the context in which the word, “testing” is used is talking about individual testing for nonepidemiological reasons, “testing” refers to widespread testing.

^[i] Wikipedia: Paul Romer

^[ii] “Fauci: Improved testing and tracing can help reopen country.”

^[iii] “Serology Testing for COVID-19.”

^[iv] “The World Health Organization has called on countries to ‘test, test, test’ for coronavirus – this is why.”

^[v] “MSNBC: COVID-19 Testing & The Road To Reopening.”

^[vi] “Dr. David Katz | Real Time with Bill Maher (HBO).”

^[vii] “The Real Issues Concerning COVID-19—Part IV, The Herd Immunity Messaging Problem”

^[viii] “‘[South] Korea was able to successfully flatten the curve on COVID-19 in only 20 days without enforcing extreme draconian measures that restrict freedom and movement of people,’ writes ministers of the South Korean government in their April 15 coronavirus playbook.”

^[ix] “Videos appear to show people in China forcibly dragged off to quarantine.

^[x] “PA Health Secretary Moved Mother Out Of Personal Care Home After Ordering Nursing Homes To Accept COVID Patients,” “Why Cuomo Reversed His Order That Forced Nursing Homes to Accept Coronavirus Carriers,” “8 times Bill de Blasio downplayed the coronavirus” and “Tucker: How local leaders failed their cities.”

^[xi] “People ‘shed’ high levels of coronavirus, study finds, but most are likely not infectious after recovery begins”

^[xii] “As coronavirus testing expands, a new problem arises: Not enough people to test”