COVID-19, Top Stories

Don’t Test, Don’t Tell: The Bureaucratic Bungling of COVID-19 Tests

“I believe that a healthy society should not have only one voice.”
—Li Wenliang, whistleblowing Wuhan physician, killed by coronavirus infection at age 34

On Thursday, February 26th President Donald Trump finished up his initial White House press conference on the coronavirus. He had appointed Vice President Mike Pence as coronavirus czar and spoke about “the fifteen cases that could go to zero.” At the same time, I received a Twitter DM from a physician that included screenshots of an email that had been sent to staff at the UC Davis Medical Center in Sacramento, California earlier that afternoon.

Since that night, the original email has been confirmed by UC Davis and reported on by multiple news organizations. Here’s a copy of the email as reported by NPR.

I want to highlight a couple of quotes from this email.

Since the patient did not fit the existing CDC criteria for COVID-19, a test was not immediately administered. UC Davis Health does not control the testing process.

The facts here are clear cut. A patient came in from another hospital on Wednesday, February 19th—one week before the emailalready intubated and on a ventilator, and the doctors at UC Davis—who have treated other coronavirus casesimmediately suspected a coronavirus infection. But the US Center for Disease Control (CDC), the organization with the sole authority and ability to administer a coronavirus test, refused to test.

Why? Because this patient didn’t fit their “criteria” for testing. These criteria—what are known as Patient Under Investigation (PUI) guidelines—have been set in stone in the United States since coronavirus first burst onto the scene a few months back. Do we know for sure that the UC Davis patient was either a) in mainland China within the past 14 days, or b) in close contact with another confirmed case? No? Well then by definition this UC Davis patient could not possibly have a coronavirus infection. No test for you! It’s not that testing was not available. It’s that testing was not allowed.

This policy can be characterised as “Don’t Test, Don’t Tell” and it is the single most incompetent, corrupt public health policy of my lifetime.

But wait, there’s more. It’s not only this patient who was directly harmed by this policy:

When the patient arrived [Wednesday], the patient had already been intubated, was on a ventilator, and given droplet protection orders because of an undiagnosed and suspected viral condition. … On Sunday, the CDC ordered COVID-19 testing of the patient and the patient was put on airborne precautions and strict contact precautions.

Translation: For four days, every healthcare professional treating this patient at UC Davis was exposed to airborne transmission of coronavirus. And so was every healthcare professional at the hospital before UC Davis, particularly during the intubation process. Because the CDC refused to test this patient for coronavirus in a timely manner, all of the doctors and nurses and technicians caring for this patient were put at risk.

Sure enough, over the next few days about 124 UC Davis Medical Center staffers—including at least 36 nurses—were ordered into self-quarantine because of their exposure to this one patient. Worse, three staff members at Northbay VacaValley Hospital—the facility where this patient was treated before being transferred to UC Davis—have already tested positive for coronavirus infection, with an unknown number of additional healthcare professionals from that hospital now in self-quarantine. That’s all from one coronavirus infection.

Now imagine this same story repeated day after day across the United States for the past two months, where those infected with the virus fail to receive the care they need, spreading the disease not only to their community when their symptoms do not require hospitalization, but spreading the disease directly to emergency responders and healthcare professionals when their symptoms do. Even today, more than a week after the consequences of Don’t Test, Don’t Tell were revealed in that first case of community-spread coronavirus from Sacramento, the number of tests performed in the US remains extremely low, particularly in states that were caught flat-footed when the CDC abdicated control over test production. Missouri, a state with a population of more than six million, has performed only 17 tests. Michigan, with a population of 10 million, has performed only a few dozen tests. Pennsylvania, with a population of almost 13 million, can perform all of 33 tests per day. Unsurprisingly, these states do not have a confirmed case of coronavirus within their borders.

Now imagine this same story repeated day after day across the globe.

As I write this essay on March 5th, there are more confirmed coronavirus infections in Harris County, Texas (five) acquired by Americans who traveled to Egypt than there are confirmed cases within the entire country of Egypt (three). Why? Because Egypt has only tested a few hundred people in this country of 100 million. There are more confirmed coronavirus infections in the city-state of Singapore (three) acquired by Singaporeans who traveled to Indonesia than there are confirmed cases in the entire country of Indonesia (two). Why? Because Indonesia has only tested a few hundred people in this country of 265 million.

With the exception of South Korea and Italy (and perhaps Australia and the UK), pretty much every nation in the world has adopted some form of Don’t Test, Don’t Tell. The offenders include rich countries like the United States and Japan, vast countries like Indonesia and India, communist countries like China and Vietnam, theocracies like Iran and Saudi Arabia, oligarchies like Russia and Nigeria, social democracies like Germany and France. Don’t Test, Don’t Tell knows no geographic or ideological boundary.

And so you might ask: Is this a difficult or expensive test to make? Is there some fundamental reason of technology or economics why a country might find itself forced to pursue a policy of Don’t Test, Don’t Tell? Nope. It’s a relatively simple test to develop and administer in vast quantities. There are probably half a dozen university and industry labs in Jakarta or Nairobi, much less Moscow or Chicago, that could crank out a few thousand test kits per week if they wanted to. Or rather, if they were allowed to.

Now that doesn’t mean that you can’t screw up the coronavirus test if you really set your mind to it. And in fact, that’s exactly what the CDC did in January, when they rejected the World Health Organization’s proposed test panel for SARS-CoV-2 (the official name for this particular novel coronavirus which causes the disease COVID-19) in favor of a gold-plated test panel of the CDC’s own design. After all, why just test for SARS-CoV-2 when you could also test for other SARS and MERS viruses? Unfortunately, with complexity came error, and these initial CDC triple-test kits had a flaw in one of the multiple tests, ruining the entire test. Now the CDC is producing a solo test for the SARS-CoV-2 virus, but this fiasco set us back weeks in test-kit supply.

So if it’s not a difficult or expensive test to make, why are so many countries pursuing a policy of Don’t Test, Don’t Tell? The answer, of course: to maintain a political narrative of calm and competence.

Two weeks ago I wrote about the corrupt political response of China to COVID-19:

A city falls when its healthcare system is overwhelmed. A city falls when its national government fails to prepare and support its doctors and nurses. A city falls when its government is more concerned with maintaining some bullshit narrative of “Yay, Calm and Competent Control!” than in doing what is politically embarrassing but socially necessary.

That’s EXACTLY what happened in Wuhan. More than 30% of doctors and nurses in Wuhan themselves fell victim to COVID-19, so that the healthcare system stopped being a source of healing, but became a source of infection. At which point the Chinese government effectively abandoned the city, shut it off from the rest of the country, placed more than 9 million people under house arrest, and allowed the disease to burn itself out.

And so Wuhan fell.

The disaster that befell the citizens of Wuhan and so many other cities throughout China is not primarily a virus. The disaster is having a political regime that cares more about short-term public and economic concerns than it cares about saving the lives of its citizens.

We must prevent that from happening here—or anywhere. Yes, containment will likely fail. But that does not mean the war is lost. We can absolutely do better—so much better—for our citizens than China did for theirs. China’s handling of the coronavirus in Hubei province, from its muzzling of doctors like Li Wenliang for “rumor-mongering” to its forced quarantines of tens of millions was all guided by Don’t Test, Don’t Tell (with Chinese characteristics).

The Chinese experience with coronavirus is not a “lesson” for the West. It is a cautionary tale. How do we do better by our citizens than China did by theirs? By prioritizing the protection of our emergency responders and our healthcare professionals, through better equipment and facilities, yes, but most of all through better policy and organization, starting with the abandonment of “Don’t Test, Don’t Tell.”

 

Ben Hunt is the co-founder and Chief Investment Officer at Second Foundation Partners, and the author of the Epsilon Theory newsletter. Follow him on Twitter @epsilontheory or email: ben.hunt@epsilontheory.com.

Feature image: Ambulance staff prepare to transport a patient from the Life Care Center nursing home where patients have died from COVID-19 in Kirkland, Washington on March 5th, 2020. (Photo by Jason Redmond / AFP) 

Comments

  1. This is enough to explain the entire situation, and it undermines the finger-wagging tone of the entire article.

    Q. Why did the CDC assert control over who could be tested? Why did they not allow testing of anecdotal case X, Y or Z?

    A. They might run out of test kits in a forseen worst-case if they allow individual citizens or front-line doctors to decide who gets tested.

    That’s it.

    Not only is that it, it’s their job. They exist to make exactly this kind of hard call that may look silly without knowledge of the national picture, the future, or the 99p unfolding of the epidemic instead of the median. Given my understanding of what they are expected to do, I’m reassured, and you’ve done nothing to change my mind.

    The rest is just hindsight bias. A delay of a week is not a “bungling” but a normal error that looks so far to have had little consequence.

    A thousand per week? This is insane envelope math. In your hindsight- and anecdote-focus did you forget to count the tests that would have come back negative?

    The other head-scratcher in your read of the hospital’s note is the language “since the patient arrived with a suspected viral infection.” What is the value of the test within the hospital?

    Let’s apply some logic.

    Releasing a possibly-infectious untested patient for “self-quarantine” could be bad because the patient, not being a professional able to discipline themselves to logic, might do a bad job of complying without the media PR around COVID-19 hanging for certain around their neck. And the test may have value to the CDC who’s tracking the disease. That’s it’s value. But what’s the value to the hospital who can, if tests are not affordable, substitute spending their standard viral-cautionary procedure for every patient they would have tested? which is exactly what they did.

    This is the kind of decision that’s made in medicine all the time: imperfect interventions must be chosen without certain diagnoses. Again, it’s their job, and they did it.

  2. I agree that you had to limit tests to the most likely initially, as witness the runs on hand sanitizers, masks and even toilet paper. And while tests may not cost much to create, they cost time and money to run.

    What was needed was a faster response to allow others to create kits and run tests, as this was only opened up recently. Clearly, this could have been done sooner as it didn’t impact the CDC, other than releasing a bit of their power/control. It’s why South Korea was able to run with their testing. We have the capacity, just not in the CDC alone, and so we needed to expand access (preserving both liberty and natural rights of care and investigation).

  3. Glad to see Ben on here. There was also the attempts by the PRC and CCP to suppress any news of the virus back in December. Given the repeat “popularity” of these communicable viruses from Asia, it might be a good idea to stockpile, and make designs available for quick manufacture of, kits that test the whole family of bugs.

  4. “The World Health Organization (WHO) has shipped testing kits to 57 countries. China had five commercial tests on the market 1 month ago and can now do up to 1.6 million tests a week; South Korea has tested 65,000 people so far. The U. S. Centers for Disease Control and Prevention (CDC), in contrast, has done only 459 tests since the epidemic began.”
    sciencemag.org/news/2020/02/united-states-badly-bungled-coronavirus-testing-things-may-soon-improve

    Clearly they won’t run out of tests, see above. Either they want to hide it for as long as possible hoping it’s not going to be bad, maybe to protect the economy or to prevent panic for as long as possible, worse is if people actually want to make it as bad as possible. The decisions not to test and to censor information going out are not in the publics best interest, whose interest are they in? It was mentioned above that the cdc wanted control, but I think that is only part of the picture.

  5. You are assuming a reason other than incompetence. This may be a mistake. One of the things that is a problem in any bureaucracy is Empire Building. You have bureaucrats trying to control a process out of reflex, mostly because they want to keep their own power over the process, or assert power over the process. This keeps them importantly employed. Bureaucratic turf wars can cause screw-ups exactly like this.

  6. The CDCP, for reasons that aren’t entirely clear, did not want to use the WHO kits for testing in the US. They instead released their own kits to state labs, which proved not up to the job. The alternative was to send test swabs to the CDCP labs, which created a bottleneck (this has since been relieved, as many labs now are able to process their own tests that CDCP will consider acceptable). However, the CDCP lab only processed 500 tests up until late February, which was as fast as they could go. Since CDCP knew that, they needed to put up some set of limits to keep from being overrun with tests they could not process and that might prevent other, more justifiable, test results from being available.

    If testing would allow a diagnosis that would lead to a treatment tailored for COVID-19 disease, one might argue it made sense to test everyone who walks in the door with a fever. But it still doesn’t deal with the bottleneck for testing, even if we have 10x or 100x lab capacity. Currently there are around ten thousand people in some form of quarantine or that are hospitalized for this disease. We know from China that testIng often shows negative until the symptoms have developed. And we don’t have a specific therapy at this point, and perhaps not ever. Testing might be good data, or it might be misleading data, but its existence doesn’t argue against using it parsimoniously and only when clearly merited by the circumstances.

    It is quite easy with hindsight to say ‘this clearly meant they had COVID-19’ but the bulk of people showing up at ERs in acute respiratory distress even today don’t have COVID-19, they have seasonal flu. Over 350,000 people have been hospitalized and 20,000 have died so far this season from seasonal flu. Seasonal flu kills the same populations. So when someone shows up with symptoms at the ER, you take universal precautions but perhaps you don’t assume everyone has COVID-19 and test because it’s in no way reasonable to do so.

    It is true that the CDCP’s testing restrictions created the “streetlight effect” (you don’t see what you aren’t looking for) but it is unclear there really was a better approach. We now know that COVID-19 has been kicking around since mid-December in China and has had community spread since mid-February in the US. But again, that is in hindsight.

    For now, wash your hands. And don’t use air dryers.

  7. No, incompetence. It doesn’t take malice, just determination to maintain the bureaucracy.

  8. You’re right. Malice isn’t the right word, but incompetence isn’t far enough. You suggested yourself they (the public servants) have selfish motives for doing what isn’t in the best interest of the public.

  9. This isn’t clear from the above. The only really large numbers of testing capacity you cite are China’s. Are you expecting China to share half their tests with us? Have they done that?

    It seems your point is that we’ve tested few people. What is that supposed to show? The way this works is that you set a protocol for when tests are allowed, and continue using that protocol even deep into a zombie apocalypse scenario. The protocol is not, “use at least 20000 tests per week on low priority stuff to keep the proles happy.”

    This could be true and “feels” concerning. The important thing here is not that ascribing this motivation to them is TDS-inspired speculation. That’s true, but not important. The important thing is that this claim is different from TFA’s claim: hiding the extent of the outbreak and making the outbreak worse are two different things.

    How would we have used more tests to make the outbreak less bad?

    I think you’re probably making an unjustified leap, “we don’t know if the outbreak is already so bad we should shut down air travel and all schools, because we’re not testing enough to know that.” These anecdotes of person X Y or Z who wasn’t tested don’t show to me that CDC doesn’t have an accurate upper bound on how bad the outbreak might be right now.

    I think people are seizing on tests as more magical than they are.

    • If people are contagious before they have symptoms
      • then testing more people who have symptoms, which is what this article is asking for, won’t help. What will help is testing asymptomatic at-risk people, which they are actually doing.
    • If people are not contagious until they have symptoms
      • correct advice is “stay home if you’re sick. Do not wait to worry you might have COVID-19 until you test positive.” Unless you are planning to administer tests with housecalls within 12 hours to everybody who gets a cold I don’t see how more patient-requested tests can help slow the outbreak in this case, either.

    I think the useful ways a test could help slow the spread would be:

    • test asymptomatic people who’ve been in contact with someone who is known positive
    • test asymptomatic healthcare workers working with COVID-19 patients periodically

    As far as we can tell that’s exactly how the tests are getting used. The point here is that you can only give tests to an asymptomatic person if you have some other reason to believe they’re positive. Unfortunately this looks indistinguishable from applying tests to minimize the number of known-positives to protect the stock market or Black unemployment.

  10. Engineering principles apply: don’t let best be enemy of the good; good enough is best. Take advantage of resources available even if you can only monitor the quality.

    Carton has a good analysis of two of the minimum criteria for testing. However, as indicated by the actual history, a third criterion is needed: people with severe and characteristic symptoms of unidentified origin in a region where cases might crop up because unknown entrance of carriers… Basically, these new, symptomatic cases would be monitors of community transfer, like sick canaries in a coal mine are monitors of bad conditions which might include high levels of methane. Without tests, there is no way to identify these new cases. Without identification, contact tracing from new, unidentified sources is hobbled. The results were the cruise ships and Washington state community transfers.

    The CDC actually did want more testing but they and the FDA set criteria so stringent that more testing was not available. o malice intended but operating out of too much caution and fear of other’s capacity to do things right. Thus the severe limits on what got tested. Kits that could be made only by the CDC were not reliable because the controls were complex, contaminated, or both. Individual laboratories that normally meet CLIA requirements were not allowed to procure and run test reagents on their own because criteria for FDA and CDC acceptance were too strict (see ProPublica article on this: https://www.propublica.org/article/cdc-coronavirus-covid-19-test).

    Since the inception of the task force and realization within the CDC, those requirements have now been reduced to the minimum necessary to show detection the virus, even if the test might accidently turn up positive if the tested had SARS-COV-1 or MERS instead: equally bad outcomes even if they cannot be distinguished.

    Better would have been to take advantage of the widespread expertise available in the United States: institutional nucleic acid testing laboratories and private companies capable of producing kits based either on the WHO standards or on new design. Such early availability of testing could have two outcomes: no sign of community spread with a bunch of negative results or early revelation of community transfer with isolation of potential carriers of unknown origin. Either outcome would have provided the CDC with essential information for managing the spread of the virus in the USA. In the absence of those results, we are at least a month behind that management and still do not have a good grasp of the extent of penetration of the virus in the population.

    The USA is a capitalist and scientifically open country: let’s take at least as much advantage of that as China did of their market economy by welcoming those resources rather than hobbling them. Literally, live free or die.

  11. Imagine if the next epidemic is much deadlier but met with the same hit & miss border controls and ‘self-quarantine’ restrictions that get treated as a joke! It seems that airlines make their own rules which our govt meekly ticks for them, while China shuts down a whole city.

  12. In my local area, 10 mil pop. they have tested thousands of people. I don’t believe many are being missed. This is possible everywhere, thousands of tests isn’t huge and in terms of the costs vs potential harms I think most people would agree it’s cost effective.

    More information equals better and better informed decisions. Deciding not to collect data during a potential public health emergency is irresponsible and simply doesn’t make sense from a public health perspective.

    I know the advice given to people is right, but why not let the hospitals run their own tests and then have it confirmed with the cdc if there is a positive. The only reason that they don’t want to do the testing, is because they don’t want that information out there. Similar to how china and iran were not exactly forthcoming with their outbreaks when they were first happening. Difference is that china can do the tests and control the information, but once the tests are done here it’s public knowledge.

    You say there is no problem, I say how do we know, you say “well, nobody has it” while at the same time not testing anyone. Neither position is validated in the least. How are we supposed to study the dynamics of an outbreak in order to protect ourselves in the future without robust data collection, can we trust the data given by foreign states, how can we even design public policy without knowing what is going on? Maybe the spread could be slowed down by small local closures where there are local outbreaks but we will never know because the govt has hands over their eyes and ears. The point is that there is really no excuse from a public health standpoint to not be testing people, they aren’t being tested for political reasons not in the publics best interest.

  13. Have either of you thought of the following question? How about “incompetence because of malice”? I don’t believe it’s an either/or argument.

    Someone dismantled the pandemic chain of command back in 2018 because of malice & incompetence. When a leader does things out of malice and/or stupidity, it helps to breed more incompetence and even malice within a given bureaucracy…

    The statement “a fish rots from the head down” means that leadership is the root cause of an organization’s failure and demise. This is true whether that organization is a country, a company, a sales force, or a government agency.

  14. It seems to me that there are currently somehow two diametrically opposed interpretations of the Coronavirus situation, of which only one can be correct.

    In one version Corona is more or less just a new version of the flu. There is definitely no reason to bother too much, to criticize well established bureaucratic routines or to take more than basic precautions like washing your hands etc. Who cares if some Corona cases go undetected? The best personal approach is to signal your composure by emphasizing that there is really no reason to worry. This version seems to dominate e.g. in the United States and in Germany. And in these countries the number of proven deaths is so low that the analysis looks really convincing.

    In the other version, Corona is a new and comparatively deadly disease with the potential to become a global pandemic that could kill tens of millions of people worldwide if its spread cannot be contained. Drastic measures are needed to avoid this scenario. The appropriate personal approach is to build up stocks, prepare for the worst, and hope that you and your loved ones will be able to survive. Countries such as China, South Korea and Italy, where hundreds or even thousands of people have already died, are guided by this version. The article’s criticism of the CDC’s behavior is also based on this scenario.

    Why do I have the impression that these two stories take place in different realities or at least describe two completely different diseases?

  15. People start with the former, then it hits and they switch to the latter?

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