Several friends have asked me about the importance of, and status of, coronavirus testing in the States. It is the single most important factor in returning to the status quo ante virus, so why is the US behind other countries? Let’s focus on virus testing today (tests to determine if one has the virus now), but what we’ll see also applies to antibody testing, certification of equipment (like ventilators) and even “proof of” processes (like testing protocols).
The President trumpets (sorry, couldn’t resist the pun) the fact that the US has completed more virus tests (3.7 million, all data as of 5/19) than anybody. Which is true. The numbers change daily, but the US has done twice as many as Germany amd six times more than South Korea. Still a little behind the EU, which is a better comparable. The President’s many critics point out that total numbers of tests are not the right way to compare nations: you should compare tests adjusted for population. They are correct: it is a better way to compare, and here the US lags in forty-second place, behind such notable nations as Russia and San Marino, with the Faeroe islands leading the pack.
Let’s take a analytic look at the data, which tell an interesting story.
All scientists and health officials agree testing (in all its types) is the long pole in the tent (a military phrase meaning the thing in a sequence of things that takes the most time, thus is critical to on-time mission completion). All agree it is essential to restoring society to normal working order. All governments are trying to get to this end state: sufficient testing to achieve normalcy. No one is sure how many tests or what percentage of the population must be tested to get there (that is a judgment call, not a scientific determination), but all agree it is large. And no one is anywhere near there yet.
Data does not include Germany, as this site does not recognize Germany’s data, but the German numbers are very close to Russia’s. If you want to play with the data yourself, go here.
So per capita testing is a valid way to describe how well a country is doing on the road to getting back to normal. But let’s go back to the total testing numbers to see how they influence how to assess the progress. Only the US, Russia, Germany, and Italy have exceeded 50,000 tests daily, and the numbers are not increasing rapidly in any country. The US has achieved around 150,000 tests daily. If testing is the long pole, and everyone needs to do a lot more testing, why haven’t those numbers spiked?
Some suspect a failure in governmental leadership, so let’s compare.
Look at Germany, considered (rightly) a world leader. They had a head start on the regional crisis (it started in Italy), a favorable set of initial cases (younger by half than that of Italy), universal health care, and a world-class pharmaceutical sector. The acclaimed technocratic German administration was alert and responsive, led by the capable and experienced Chancellor Angela Merkel. They recognized testing was a challenge, and engaged both government and commercial resources on the problem. And the end result is they have done 1.7 million total tests., about 70,000 a day, with a goal of 200,000 a day.
Look at South Korea, another obviously positive case. Again, an early start at social distancing, a culture accustomed to wearing masks and willing to abide government restrictions, universal health care, good high tech manufacturing, world’s best internet penetration and adoption, and recent experience with MERS (Middle Eastern Respiratory Syndrome, a coronavirus which hit in 2015 and left ample lessons). Which resulted in half a million total tests, stuck at 10,000 test a day.
Is Germany not as sophisticated as we imagined? Did Angela Merkel not emphasize the importance of testing? South Korea has done well in many areas, but if testing is the key, they have only tested about one percent of the population, with almost no growth in the testing rate per day. Who’s to blame in these countries?
The answer lies in a simple observation: testing is hard. It is not at all like surging to make tanks in World War II (which were cheap and functional–long unrelated anecdote at the end of this post*). If testing were easy to scale, some scientist or company or leader would have done it. If you look at the testing numbers, they roughly correspond to a nation’s pharmaceutical research and/or production capability, nothing more, nothing less. And they are increasing at a roughly the same rate, everywhere.
Sherman still for sale . . . 
but test arrays not so much!
To paraphrase what my old Army Master Sergeant would have said, “You can crap out a a zillion M4 tanks, but you can’t crap out a zillion coronavirus tests.”
How hard can virus testing really be? Well, every year we have to prepare a new test for that season’s flu virus (not talking about the rapid diagnostic flu tests, those are a shortcut we accept). We know it will only be a variation of what has come before, we know roughly when the flu season will start, and we know many thousands of people will die without tests (and vaccines). And it takes the full year between flu seasons to get it done.
Testing itself is a complex, multi-step process: You need the different reagents, production capability for the test kits, distribution and training for end users, a system for administering the tests and collecting samples, logistics to consolidate tests and transfer them to labs, lab capacity to evaluate tests, and a system to provide results. Some parts can be streamlined: there are multiple sources for reagents and training may be simplified. The government can play a role in establishing mass testing sites and moving materials. The internet provides an easy means to transmit notifications. But building tests? Creating evaluation capability? Not easily scalable, or someone, somewhere would be doing it.
Virus testing is closer to “nuclear power” complex than to “WWII tank” difficult. No one ever said, “hey, let’s spit out a thousand or so nuclear power stations in order to move to clean energy now.” Setting aside the politics, nuclear plants are difficult to build, require costly engineering and rigorous testing, and we have no tolerance for failures of any kind (rightly so). No nation wants faulty tests, or insensitive (false negatives) ones, or nonspecific (false positives) ones. The infrastructure for making tests can’t just be inflated. They can be increased at the nargin, and we are seeing that in many countries right now. New test equipment or processes have to go back through the same rigorous protocols, so again there is no shortcut.
Some things just take time. We are right to be impatient, but wrong if we ascribe blame when there is no alternative. Perhaps the problem is we’ve become used to modern medicine’s ability to do the seemingly impossible. We’ve come to expect science and medicine to do miracles. Read that sentence twice; the non sequitur should be obvious. That is the root of the problem. When science and medicine fail, we look for someone or something to blame. It may be rational, but it may not be correct.
* Back in the US Army in Germany in the eighties, we would go out on maneuvers for weeks, tramping around the German countryside. At the end of an exercise (ENDEX), there would be a day or so pause to re-organize before heading back home to garrison. The officers would find the nearest gasthaus and go for dinner and bier with the locals. It served two purposes: first to thank the locals for indulging our tearing up their farm fields, and second to blow off steam with a schnitzel and a great beer. We’d inevitably meet up with some old German WWII vets, who always told us they fought against the Russians. (Thus began a local joke: we won WWII because when we landed, Normandy was empty, since all the Germans were on the Eastern Front). One night, there was only one German left at the stammtisch when the night ended, and after several rounds of bier and Jagermeister, he fessed up to fighting on the Western front! We had to ask: what was it like fighting the US Army? “Ja, ich hatte es gern” (I liked it) he slurred, “when you hit the American tanks, the top popped off like a champagne cork!” We all grew quiet at the weight of what he said, and what it meant. “Good thing you got that fixed!” he quickly added.
Great read as usual