Testing NOW

 Marko Djurica/Reuters

The United States has a restless population straining against limitations on social meetings ranging
from family gatherings to public education to basic transportation to business operations to public elections to religious observances to restaurant meals to sports events and musical concerts.

That it came to us from China reflects badly on that country.

That we cannot rally a sufficient and timely response reflects badly on us.

What is worst is that we cannot ramp up two basic testing programs that would be the most effective ways to start digging ourselves out of this hole.


Testing for Antibodies

Three interesting but isolated news items were released this week.

1) All the residents of a homeless shelter in South Boston were tested for Covid-19.  Among the 397 men tested, 146, or more than a third, were experiencing coronavirus.  None had any symptoms.

2) A small-scale serological blood test for Covid-19 antibodies in Santa Clara, California, suggested that many, many more than the number of residents reported sick with the illness already had been infected and were done with it.
         (Experts are pissing all over this test based on who was sampled and statistical grounds, but in general, false positives are far less common on antibody tests than false negatives.)

3) A random testing of 200 persons in Chelsea, a dense Boston suburb, found that one-third had Covid antibodies and, again, no previously reported symptoms.

Tests like these are anecdotal and, yes, too limited.  BUT they suggest that what researchers long have suspected:  A significant portion of persons who become infected with Covid-19, perhaps one-third, experience no symptoms.  (I heard this most recently from a friend who is a professor of pharmacology.) Another number of those infected, also uncounted, have mild symptoms and take care of themselves at home.

In Southern California, word is that doctors and nurses (and, one hopes, other workers in medical facilities) are being given serological blood tests only now.

Antibody tests require less intensive production and analysis than tests for active infections.  Why not make them broadly available, starting in the hot spots like New York, northern New Jersey and Boston?

If you had antibodies to Covid-19, wouldn't you like to know?  Wouldn't you want to help your relatives with shopping or home schooling?  Wouldn't you like to get back to work at some job, even if your old one had been eliminated for the duration of this period?


Testing for Infection

At present, the US is doing more testing for Covid-19 than ever:  about 150,000 tests per day.

Also at present, unless you are symptomatic, you cannot get a Covid test unless you are an NBA player or some kind of celebrity influencer.

"Experts" tell us we need 500,000 to 700,000 tests per day to better manage the situation.

I say the experts are wrong. We need millions of tests per day, starting three weeks ago.

Here is why:  People are agitating for a lifting of some of the quarantine restrictions.

In some states, they are demonstrating in crowds that don't do social distancing.

In Southern California, the resistance is milder -- a tripling of road and pedestrian traffic in recent weeks, but with social distancing maintained -- but every park has been closed and fenced off.  The parking lots by the beach have been closed. People who walk on the all-but-empty beach boardwalks are yelled at by police bullhorns and threatened with $1,000 citations.   Last week I saw a police helicopter hover for 10 minutes over two sailboats to hector the sailors back to port.

I'm sure the enforcement is well-intentioned, but it is reaching a straining point. There is no way we can keep 327 million people and most of the economy shut down until autumn 2021, the most hopeful date for an approved vaccine and broad-scale immunizations.

The problem with even the most limited opening now is that it will be accompanied by a new rise of infections, one that probably will be smaller but that could be ameliorated by making tests much more broadly available.

It's time to test people who don't have symptoms.  Infected people can spread the disease before they get sick; identifying even a few of those BEFORE they get sick or acquire antibodies would prevent further infections.

Anyone who wants to be tested should be able to get tested, period.

This must be done sooner and not later.


Why

My first argument for testing is that a nation that can commit $2.2 trillion for subsistence payments to people and small businesses -- more than $8,000 for every single person in the US -- should damn well be able to provide infection AND antibody tests for every one of those persons.

But, pathetically, the problem is not one of cost.

Unfortunately, we do not have the manufacturing or staffing capacity to administer such tests.  Rich as we are, we have insufficient "supply chains."

Shame on us.

The limits we face at this moment are hinted at in this part of a broader commentary by Marc Andreeson.  I recommend reading the whole piece.

Part of the problem is clearly foresight, a failure of imagination. But the other part of the problem is what we didn’t *do* in advance, and what we’re failing to do now. And that is a failure of action, and specifically our widespread inability to *build*.

We see this today with the things we urgently need but don’t have. We don’t have enough coronavirus tests, or test materials — including, amazingly, cotton swabs and common reagents. We don’t have enough ventilators, negative pressure rooms, and ICU beds. And we don’t have enough surgical masks, eye shields, and medical gowns — as I write this, New York City has put out a desperate call for rain ponchos to be used as medical gowns. Rain ponchos! In 2020! In America!

We also don’t have therapies or a vaccine — despite, again, years of advance warning about bat-borne coronaviruses. Our scientists will hopefully invent therapies and a vaccine, but then we may not have the manufacturing factories required to scale their production. And even then, we’ll see if we can deploy therapies or a vaccine fast enough to matter — it took scientists 5 years to get regulatory testing approval for the new Ebola vaccine after that scourge’s 2014 outbreak, at the cost of many lives.

Dead-End Testing

It’s the type of inertia that clearly frustrates Romer.  He calls the $2 trillion legislation passed by Congress “palliative care” for the economy. 

If you took $100 billion and put it into testing, 
he says, we would “be far better off.”

MIT Technology Review, April 8 2020

The article cited above makes more sense than almost anything else I have read about Covid-19 this year.  The quote is from NYU economist Paul Romer, who deserves more attention than our bumbling public health experts.

Here's the point:  If U.S. coronavirus testing had been handled better, fewer people would have died, many people would have been spared a miserable illness and the national economy might not be careening into what looks like a very deep, very expensive recession.  (More about the economy another day.)

So let's talk about testing, starting on January 20 of this year.

We all remember January 20.  That was the day the World Health Organization and China acknowledged, at long last, that Covid-19 was a contagious virus that was passed from person to person.  (This had been understood in China by December 6, 2019, and by everyone else not much later.)

Also on January 20, the United States and South Korea announced the diagnoses of their first Covid-19 patients.

The differences between the two countries' reactions -- specifically, their testing rollouts -- is worth a closer look.


South Korea

On January 27, when South Korea had a total of four patients, the South Korean Center for Disease Control sent an SOS to Korean medical labs, promising streamlined approvals for Covid detection tests.

The first test was approved on February 4, and a second one on the 12th.  By March 15, when a fifth test was approved, the country was testing 20,000 persons daily.  Daily diagnoses peaked at 909 on February 29, then dropped to 93 by March 18 and since then have rumbled at a very low level even as testing has continued, as seen below.

South Korean testers also contacted and tested the friends and neighbors of those who had tested positive, and almost every single member of a large church where hundreds of congregants had tested positive.  Because the tests had been given quick approval, their results were cross-checked against each other as the rollout continued, to assure validity.

In the world of disease prevention, these activities are known as Public Health 101.  South Korea now is manufacturing and providing Covid tests for many other countries.


United States

In the U.S., the CDC preferred initially to design and release its own test, starting February 4.  Four days later, reports began to surface about the test's unreliable results.

Another problem was the lack of tests.  Curiously, Kaiser Health News reports, the CDC distributed its first batch of tests in equal numbers to every one of the 50 states.  Sounds wacky to me, but, hey, I wasn't there.

On February 27, California's governor said the state had identified 33 persons with Covid-19 and was monitoring another 8,400 persons who had Covid-like symptoms.  Testing was going slowly, he said, because the state had only 200 CDC tests on hand. 

(NB: California is home to 40 million people, about 80 percent as many as live in South Korea.)

On February 29, the Food and Drug Administration gave its first go-ahead for non-CDC tests developed by pharmaceutical companies, universities and medical laboratories.

One week later, the U.S. had conducted 2,000 tests and South Korea 80,000.

There were other problems.  Because U.S. tests still were scarce, the CDC recommended testing only for people who had been to Wuhan or who had met people from Wuhan or who had Covid-type symptoms.

This approach did nothing to seek out people who had been in contact with sick Americans.  It did nothing to identify infected persons who were pre-symptomatic and contagious, let alone to tell such persons to isolate themselves.  Later, state by state, almost the entire U.S. population was ordered to quarantine, an edict with no end date in sight.

The US version of the Korean chart, above, mostly tells us how much later testing started here.  Its fast-rising trend line almost certainly reflects only the increasing numbers of tests performed; the inference that infections may have peaked in the last week (five weeks after the peak in South Korea) may be true or may indicate a lull in the daily availability of tests.

Worst, it tells us nothing about the number of infected persons in the country, because, again, testing was reserved for symptomatic people who were lucky enough to get access to tests (plus a good sampling of politicians, celebrities and tigers in a zoo; one of the last group was heard coughing and so six were tested "out of an abundance of caution.")   One hopes medical workers were given broad access to testing, but news reports suggest that may this may not have been the case.

In one perhaps typical case, the state of New Jersey, a domestic hot zone for the virus, set up a drive-through test site in late March.  When it opened at 8 a.m., the line of idling cars was miles long.  After 35 minutes, the line was closed because there were not enough tests for all the drivers who were waiting.  Testing stopped by noon.
           Last week, about six drive-through test days were announced in one New Jersey county, and persons with high temperatures and Covid symptoms were invited to make appointments for the limited number of tests available, roughly 100 to 250 per day.  The available appointments filled quickly, and 5,000 requests were denied.  Maybe in a couple weeks, or maybe in May ....

A friend shared the story of a Pennsylvania family man in his early 40s who ran a fever for two weeks and then got a Covid test whose results were promised four days later.  After two in-patient stints for major pulmonary interventions and after his second hospital discharge, he got his test result -- yes, he did have coronavirus.  Good to know, huh?

You can read more about these matters in articles from Reuters and the increasingly valuable Kaiser Health News.

-----

The conclusion here is this: After a late, slow start, the U.S. has piles of test results that reveal very little in the way of useful information.   We still have no idea how many people in the U.S. were infected, or are infected or might develop symptoms.  We never will know how many of this season's "flu deaths" were actually Covid-19 deaths.  If we have flattened the curve, it was by curtailing the movements of everyone for a period of time whose end we cannot forecast.

"The system is not really geared to what we need right now," the estimable and understated Dr. Anthony Fauci told a Congressional committee in March.

"That is a failing. Let's admit it."

-----

Given the cynicism engendered by the original testing program, it might sound odd to say this, but here goes:  The best hope for minimizing Covid damage in the U.S. is more tests.  

The new testing would be for antibodies.  Testing for such, done with pinprick blood samples, could identify people who are Covid-19 survivors and who have developed immunity to the virus.

Theoretically (and I do mean theoretically, given recent history) many of these tests could be done fast and yield answers within hours.  

The people who test positive for antibodies could go back to work and help start the revival of our comatose economy.  They could staff grocery stores, drive delivery vans, plow and harvest food crops and give medical workers some deserved relief.  They also could donate their plasma, which in very early testing has seemed to benefit seriously ill Covid patients.

This would NOT end basic coronavirus testing, however.  Those with no antibodies would need to be tested, probably repeatedly, for Covid infection and/or would need to remain quarantined until those slowpokes at the Department of Health and Human Services approve a Covid vaccine and get it to those who need it.  In a perverse way, those lucky enough to avoid infection will have to limit their movements until immunization provides their get-out-of-jail-free cards.

(In my dark imaginings, HHS will deploy Google to monitor the compliance of those without antibodies or immunizations by tracking them using data from their cellphones.  This capacity was revealed in recent weeks when residents of some cities were admonished for walking or driving too far from their houses and -- theoretically, again -- endangering others.  It doesn't take a Constitutional lawyer to wonder whether this isn't a Fourth Amendment violation.)

In any event, no immunization is expected to gain FDA approval for at least 18 months.  The restriction on movement during that period will be less popular than the proverbial ants at a picnic.


Note

Another upside to antibody tests -- again, IF we can organize and administer them -- would be establishing how many persons, if any, acquired antibodies without experiencing a traditional case of Covid-19.  The hope is that there are many of these people, but, again, we don't have the facts.  

Such tests also would answer a nagging question in the American West:  whether many Americans caught minor cases of Covid-19 and, with it, acquired immunity last winter.  There is a developing belief that minor Covid exposures lead to less serious cases, and the cases at issue arose and were resolved before very sick people began clogging hospitals, at least in New York, in mid February.   

This writer is one who would like the question answered.  I flew to California at the end of December and then coughed continually starting shortly afterward and for almost a month.  If what I had was a cold, it was a strange one (no stuffy nose, no fever) and my first in almost 20 years.  One of my siblings, in another state, had the same bug.  Another sibling flew out of a small town that later saw many Covid cases and arrived home with other odd symptoms.

For the record, if I do have coronavirus antibodies, I will be happy to donate as much plasma as I am able.   

Rethinking Face Masks

A month ago in Prague

I'm so old I can remember when Covid 19 (which recently was renamed Covid-19) was not such a big deal.

First we were told not to gather in groups of 500 or more, then in groups of 250, then 50 and then 10.  Finally, we were ordered to go home and stay there.

(Meanwhile, the amusingly named Centers for Disease Control was applying its not-invented-here mistrust of South Korea and major pharmaceutical companies and developing its very own Covid-19 test -- which didn't work and wasted weeks while the virus spread.  Great bunch, that CDC.)

Now our public health bureaucracy is in the middle of a similar evolution on the matter of face masks.

As we know, a month ago the word was:  Don't get a face mask!  First responders need them more!  Don't be selfish!

As long as we kept to ourselves, we were told, the biggest danger was touching surfaces that had been touched previously by infected persons, including ones who were not yet symptomatic.  The things to do were to stay in the house and wash our hands many, many times each day.

So I didn't even try to get a face mask.

(I even read an article about a company that proposed to make a big batch of N95 masks, the kind that first responders need and that are still in very short supply.  The apparatchiks at the CDC or FDA responded thusly:  It will take us at least 45 days -- and possibly 90 days -- to evaluate and approve your design before you can start manufacturing masks.  I remember thinking:  Are these bureaucrats too busy to put a rush order on something that seems kinda important?  Do they want more masks, or do they want to shut down their work-from-home computers at 4:30 p.m. every single day?)

Even as a non-expert, I thought the no-masks-for-the-general-public drumbeat sounded off.  If Covid-19 afflicted the lungs, which it does, why not limit the degree to which people breathe on each other in public -- just to be careful?

Among Asian immigrants, I had noticed a practice of wearing masks occasionally in public (not N95 masks, just basic paper ones.)  When I asked a friend why, she explained that masks were worn when people didn't feel well and didn't want to make other people sick.  Seemed like a nice idea.

While Americans were being told not to hog the face mask supply, people in the Czech Republic (or Czechia; hard to keep up) also were being told to stay home and, if they had to go out, to cover their mouths and noses.  The innovative Czechs donned masks and antifa-style gaiters and head scarves.  Shockingly, this seemed to reduce the spread of the coronavirus. 

After a few weeks, Americans got wind of this strange new innovation.  The quilting community, particularly, began sewing masks by the hundreds.  If you want to make some yourself, YouTube has many patterns and ideas for how to go about it.

But then, as happened with toilet paper, the 1/4-inch elastic used to secure such masks behind the ears soon became scarce.  Perhaps it was because the stores that sell sewing accessories had been deemed non-essential and were closed for the duration.  Or perhaps some seamsters were hoarding.  I do not pretend to know.

Anyway.  Here is a perfectly satisfactory mask recipe  for those who own tee shirts, which I am pretty sure is just about all of us.   If you make one for yourself, I recommend wearing it with a hat, to cover the not entirely attractive top knot.  (OTOH, the top knot might accessorize nicely with a man bun; just saying.)

You're welcome.


Another Covid-19 Evolution

In the early days of Covid, we were told not to hug or shake hands with other persons, and also not to get too close to them.  We were given a new name for this: social distance.

Initially, social distance was defined as one meter (a tad more than three feet for those still on the English system) between persons.  Then the perimeter was pushed out to five feet, then six feet.

All fine.  Those in my household obeyed when walking on the street and when waiting on stretched-out lines to buy groceries or prescriptions.  Around here, we pride ourselves on compliance.

Then, earlier this week, an egghead at MIT said that we were Doing It All Wrong.  The appropriate social distance, said the expert, was 27 feet.  This had something to do with the potential for explosive, possibly meteoric, nose explosions.

Then Dr. Anthony Fauci, the most trustworthy source we have at this moment, said no, there was no need to adopt the new guideline.  Turns out we do not need to limit our conversations to people who live in other counties.

Here is a helpful example of the kind of sneeze Dr. Fauci regards as not requiring wary vigilance.  It comes from the comic oeuvre and involves Tom employing a pepper shaker to get himself out of a tight spot.





Note

Across the country, mayors and governors and important public health officials have begun rethinking their advice, again.  Some now are saying, maybe we should begin requiring people to cover their noses and mouths when they go out.

As usual, these chuckleheads are late to the party.  I went to a farmers market last Sunday, and just about everyone in the place had covered his or her mouth and nose with a mask or scarf.

And, of course, when this new edict is announced it will include yet another stern warning for all us stupid people:  Don't even THINK of hoarding N92 masks!

Talking about Toilet Paper

Above is an advertisement for the sort of machine that in recent weeks would make its owner popular in any American neighborhood.  One of the most puzzling responses to the coronavirus outbreak has been the hoarding of toilet paper.

As one raised in the Pacific Northwest, I am more familiar with the forest products industry than many.  And, as an avid fan of industrial plant tours, I have been privileged to observe a more advanced version of a similar machine in action.

The machine I saw has an automated feed of long "parent rolls" of rolled paper and also an automatic cutter function.  Once cut, the smaller rolls are packed in 96-unit boxes and shipped to industrial customers and government organizations like school districts.

As it happens, the machine is one among many different types in a paper factory founded by a longtime friend.   His business model is to buy large volumes of raw paper and fashion them into products sold in bulk, not in retail stores.

I called my friend recently after reading of a toilet paper heist: Thieves had shattered the rear window of an expensive automobile and made off with two 12-packs of Charmin Ultra Soft.

My friend had his own story.  One client of his, a porta-potty company, was burgled and relieved, so to speak, of its supply of toilet paper and hand sanitizers.

These are desperate times indeed.

"I don't get the tissue hoarding thing," he said, which makes sense: The Covid-19 virus doesn't seem to correlate with a need for more frequent bathroom visits.

"Honestly, I expected our hand towels to be more popular," he continued, "but maybe more people than you think do their business at work every day and now that they're home, well...."

("Doing their business" seems to be industry-speak for you-know-what.)

Perhaps I'm more cynical.  I'll bet that, till now, not many employers kept the company TP supply locked in janitors' closets.  My guess is that workers were panicked by empty tissue aisles they had seen in grocery stores and then reacted by taking employers' tissue rolls home from work.  (For the record, I do not approve of this behavior.)

Anyway, my friend's business is good.  Tissue orders have doubled, and he's turning away inquiries from potential new customers.

"I have paper when other people don't have paper.  I could sell a lot more, but I'm sticking with my regular price structure," he says.

To meet demand, he's added Saturday and Sunday overtime shifts, "but that's it. Most of our guys have families.  If one of them gets sick, I'll close for a couple weeks."

Like all my longtime friends, he's an upstanding individual.




On a Related Topic

This writer typically spends winters in a Southern California beach town; this year's visit has been extended, naturally, by the unavailability of airline flights out.

The current locale is home to a large number of homeless persons, mostly young white guys, who seem to have learned since 2019 that their confreres up north in San Francisco have been "doing their business" on local sidewalks.  The local denizens now have adopted the same practice.

I discussed this with a police officer I saw on the sidewalk last week.  "We have to observe them actually doing it to write a citation, " he said.  The expression on his face seemed to indicate a sentiment like this: I-didn't-go-to-the-police-academy-to-catch-grown-men-pooping-in-public.   But I could have got it wrong.

Meanwhile, the city's dog owners seem to have relaxed their standards in a similar way.  On the day before the local library closed, I looked out its window and saw a leashed schnauzer take a dump on the sidewalk outside.  Afterward, the dog and his owner walked away.  The schnauzer droppings were still there when I left.

(I haven't been back since, of course, and so it's entirely possible that some civic-minded person with a shovel and free time scooped up the feces and deposited them in the garbage can on the corner.)

Then, last week, on the grass space between my building and the beach sidewalk, one of my sneakers stepped into a human- or Labrador-sized pile of poop; my experience hasn't equipped me to discern which variety it was.  I walk with greater care now.

At this moment and in this location, the veneer of civilization seems thinner than a square of single-ply toilet tissue.


Note -- April 3  Turns out my friend's analysis was correct.