Move over the mimosas because America has a fresh New Year tradition: fighting to be tested for COVID before returning to school or work. The queue for brunch was replaced last weekend with line after line after row of tired citizens waiting to receive their viral permission. Test backlogs will only get worse from here as the number of cases continues to rise. But amid the complaints about the lack of fast test sets and long delays for lab results, I am reminded of the saying “You are not stuck in traffic. You are traffic.” Yes, the system failed us: Insufficient public investment in the country’s test infrastructure has exacerbated congestion, but we can also help ease it – and clear the way for those most in need of their results – by staying out of the way when it’s possible.
After weeks of bad pressure, the government is now trying to intervene more aggressively. “I know you’re really tired and I know you’re frustrated,” President Joe Biden said before the holiday, announcing that his administration would provide 500 million quick tests away from January. But even if this improves test traffic somewhat, it will not solve our national shortcoming. At the time of Biden’s statement, the government had in fact not finalized the contracts for the massive purchase. Newly approved home tests from Roche and Siemens will also be launched in January, but their supply will only count in “tens of millions”, at least initially. In terms of laboratory testing, the short-term outlook may be even weaker: PCR technology cannot be scaled as easily as simple antigen tests. Over the past two years, laboratories have worked around the clock to offer millions of PCR assays daily, but further expansion has been hampered by global supply chain disruptions and a protracted staffing crisis.
It is possible to feel indignation over this situation while behaving as responsibly as possible, given the circumstances. This is the test version of vaccine equity: the efforts to ensure that life-saving inoculations do not disproportionately benefit the healthiest and richest people. When the same principle is applied to diagnostics, it means that people with the lowest risk of COVID should not buy large stocks of home tests or take PCR appointments when they are not experiencing symptoms.
Many of those queuing for rehearsals this week do not have much to choose from in the case; Negative results may be necessary for travel or school or access to public places. But other types of COVID screening – before and after family reunions, for example, or while visiting nearby vacation destinations – are optional. It may seem ruthless to suggest that people review less surveillance; yes, the standard expert’s position has been the opposite, that we should all screen ourselves as often as possible to help reduce the spread of society. But even with increased testing, we have little chance of controlling Omicron this winter at the population level. And testing is so far a zero-sum game. Every unnecessary cotton swab you take means that fewer are available for more important purposes – such as diagnosing a symptomatic infection.
We have reached a point in the pandemic where diagnostic tests are medically crucial. The FDA recently approved two antiviral pills for the treatment of early COVID infections: Paxlovid and Molnupiravir. Paxlovid, the more effective of the two, can prevent up to 88 percent of hospitalizations or deaths in people who start taking it within five days of symptom onset. A more well-known treatment, remdesivir, can also help prevent serious outcomes – but it works best when given early in the disease. In other words, it has never been more important for vulnerable patients to know as soon as possible that they are infected. Sick patients who struggle to get a home test or have to wait days for a lab result may find themselves unable to be eligible for time-sensitive but life-saving procedures, Walid Gellad, a professor of medicine at the University of Pittsburgh, told me. We do not want our limited test supply “bound by people who just want to know so they can visit their friends or go to the opera.”
Everyone should do what they can to free up test resources for those with symptoms. We should also try to allocate tests based on underlying risks. Overall, the unvaccinated are most at risk of being hospitalized and dying from the virus, so it is also generally the people who benefit most from having those around them screened for infection. When social bubbles are what they are, I suspect many people with arsenals of home testing spend much of their personal time around other vaccinated and relatively low-risk individuals, which at best makes the public health benefits of their personal screening programs marginal.
Two main categories of people remain at serious risk of dying from COVID despite vaccination: the elderly and the immunocompromised. Older people and people with severe immune system defects will reasonably take extra precautions while socializing – including asking their close contacts to make extensive use of rapid tests. Outside of nursing homes, however, there has been little effort in the United States to prioritize diagnostic access for these groups. Instead, we face an awkward situation where many universities perform thousands of tests a day on young, vaccinated and largely healthy students, while high-risk individuals and their relatives struggle to keep up with surveillance. Well-heeled companies like Google even send employees – many of whom still work from home – some of the most sophisticated COVID detection tools on the market. “The concerned, wealthy well is doing a lot of testing of uncertain value,” epidemiologist Daniel Morgan of the University of Maryland told me, while “lead time is blowing up for higher value applications.”
It is true that testing low-risk individuals can break chains of infection that eventually reach the more vulnerable, but this will be of little consolation to susceptible members of society who cannot even ensure that their direct contacts have been purged of infection. In short, you may want to consider testing your children before visiting grandma, but checking them out after each volatile or outdoor interaction with someone who may have been infected provides marginal benefit. And if we really want to be serious about test value, universities and companies should donate their diagnostic capacity to nursing homes and high-risk nursing staff. Healthcare providers, schools, and employers can also refrain from asking for PCR confirmation when someone has already proven positive by a quick test, at least while infections are so violent.
Public health experts could lead this accusation and model diagnostic frugality. Instead, many have modeled something completely different by using social media to showcase their own extravagant consumption. I’ve seen my medical colleagues tweet photos of their private stocks of rapid antigen tests so they can check on their families daily while on vacation. Medical influencers have noble motives for sharing their aggressive COVID surveillance strategies, but given the lack of supplies, their messages seem far less useful than they think. “There are 2 pandemics: one 4 the rich and one 4 the poor.” tweeted the doctor and journalist Elisabeth Rosenthal, who admitted to being “weird” about these flashy exhibits of test abundance. She’s right: in theory, it’s a good idea to show how frequent testing can be used to protect your family and your community. In practice, we should leave tests on the shelves to other people.
I will admit that I am just as self-interested as any other human being. Despite recognizing the need for vaccine and test cheapness, I received three Pfizer injections as soon as I was eligible and I have kept a lot of quick detection kits in my closet. But my own cognitive dissonance, and that of other privileged people, has become untenable in light of Omicron’s rise. Given the reality of our test shortage, it’s time we start cutting back on where and when we can.