The White House outbreak is a big wake-up call to all of us.

Welcome to Plugging the Gap (my email newsletter about Covid-19 and its economics). In case you don’t know me, I’m an economist and professor at the University of Toronto. I have written lots of books including, most recently, on Covid-19. You can follow me on twitter (@joshgans) or subscribe to this email newsletter here.

I have to admit that after the news that the US President had tested positive for Covid-19, I had decided that I would take a week off writing this newsletter. I just didn’t know if I had anything to say anymore. But a few hours after that decision, the theme of the moment really hit me: complacency.

The complacency I want to talk about is not the desire of some governments to downplay the virus and its risks. I don’t have anything original to add there. The complacency I want to talk about is the more human, more individual, complacency that barks at the heals of all of us during a crisis that is drawn out. How easy is it to let our guard down? Much of this is re-optimisation. For instance, we are pretty confident now that our Amazon packages are safe and that surfaces don’t need constant cleaning with respect to Covid-19. But there are other things. How close we get to people being a big one. But also things that ought to be routine.

I worry about this because I, along with so many others, are advocating using tests and screens to get us out of this mess. If we solve the information problem, we can live close to normal with the virus. The issue is that the information problem isn’t a problem with a solution. Instead, it is a problem that requires management. There is unlikely to be a once-off and we’re done outcome. What is required is continual adherence to protocols.

The White House had the Right Protocol

The one place, literally in the world, that has the resources and the motivation to manage an on-going information problem is the White House. To keep the virus out of there required constant, daily testing of all personnel along with ensuring that people acted safely when outside of the White House. Do that and you can operate as per normal inside the bubble. And it wasn’t going to necessarily require perfect compliance outside of the bubble. It just needed to ensure that the path to direct contact with the President went through a testing regime.

Some have started to blame the tests themselves. This is from the New York Times:

For months, the White House’s strategy for keeping President Trump and his inner circle safe has been to screen all White House visitors with a rapid test.

But one product they use, Abbott’s ID Now, was never intended for that purpose and is known to deliver incorrect results. In issuing an emergency use authorization, the Food and Drug Administration said the test was only to be used by a health care provider “within the first seven days of symptoms.”

The ID Now has several qualities in its favor: It’s portable, doesn’t need skilled technicians to operate and delivers results in 15 minutes. Used to evaluate someone with symptoms, the test can quickly and easily diagnose Covid-19, the disease caused by the coronavirus.

But in people who are infected but not yet showing symptoms, the test is much less accurate, missing as many as one in three cases.

Now I looked carefully at ID Now in a previous post. Here is what I wrote:

If you are running a dentist office, hospital or airline, what you want is a test that clears an individual as safe for a certain period of time. Because PCR tests can take a day or more to yield results, for clearance, organisations have been looking at rapid point of care tests that can return a result in a few minutes. One such test is the Abbott ID Now system. It is a PCR test and machine that was developed way back in March. It has been controversial.

The issue is sensitivity. An initial study comparing it to gold standard PCR tests (actually even more sensitive than the ones commonly used) found that its sensitivity was low; 87% rather than 98% for the gold standard. This is a problem because, as noted earlier, for clearance you want tests to have high sensitivity implying that there are fewer false negatives or people who are infected that you clear.

The problem with this scoring is that it is not calibrated for the decision context which is for infectiousness rather than infection. You do not care if people are infected but not infectious for clearance. The initial NYU study was published in August and noted that ID Now failed when there were low viral loads but omitted the data on that issue. The pre-print has that data which makes it clear that ID Now was highly sensitive for infectiousness.

My point was that if someone is infectious, then ID Now will (a) pick that up according to the published research and (b) will let you know right away. This is exactly what you want to do.

This study, of course, assumed you used one of those long nasal swabs to get a sample. But, in practice, people were using the shorter swabs. In May, NYU researchers put out a study suggesting this practice was lowering sensitivity. It suggested a false negative rate of 50 percent. But, when I looked at that study, I found that, again, it all depended on the viral load of the subject.

Results of the initial verification of the Abbott ID NOW revealed that it performed well with respect to the reference method when a specimen (Sample 1) with low N2 CT value (9.3) was progressively diluted up to 1:100., but this was not the case for Sample 2 with had an initial higher N2 Ct value (30.8) (Table 1). Decreased sensitivity was noted at 1:10 dilution level (approximated Ct=33.8) and beyond with only a 33% agreement at 1:100 (approximated Ct value of 36.8).

They wrote, “beyond a Ct value of 38, ID NOW performance became increasingly less reliable.” My medical friends tell me that a Ct value of 18 or below is the right threshold for infectiousness. In other words, ID Now was doing its job even when using shorter swabs. The conclusions did not change with the published paper.

I do not know what practices the White House was using to obtain samples and whether there was some dilution. But these studies indicate that should not have mattered so long as people were being tested routinely and frequently. Moreover, if that had been done, it should have been possible to hold meetings outdoors without masks for a couple of hours.

The White House is Symptomatic of Complacency

The challenge of a screening protocol in a high-risk environment is that it is fragile. If there is one person who comes into contact with any others who are not being tested frequently, the entire system can break down. If there are many, the virus not only gets into the bubble but spreads throughout it quickly. For this to have happened, the most likely cause is that protocols were not being adhered to. There are news reports that testing was not happening daily. That people were too busy.

But we knew people were going to be busy. We knew people would think there was an exception. In that environment, that means you have to cede authority to others to prevent those exceptions — from everyone! Put simply, it is precisely because this is a high-stress environment that the right frame of mind is to treat everyone inside it as a 4-year-old (and yes, I know there is a broader theme here) but, in reality, this applies to everyone regardless of whether they are an adult in real life or not. When it comes to following these rules, they should be presumed to be children and a nagging parent with authority needs to be installed at all points of entry.

My point here is that the danger is to think of the White House as exceptional in some way. It is not. The dangers it put itself into are the dangers that everyone else without resources and lines of authority are going to face. If you have a place of business which is open because of a screening protocol, then there needs to be someone who can tell the CEO they can’t enter unless they are tested regardless of how important it otherwise is. This holds especially for planes. Perhaps ironically, the places where such complacency is less likely to manifest itself will be schools. This is because everyone, including the children, knows who the children are.

My guess is that many organisations right now should take a long, hard look at their practices and see if they have a protocol that is complacency-robust. From my perspective, that means a super-ceding authority but, as every parent knows, that is easier said than done.

The Risks were Great

The White House needed to have strict protocols. The dangers of not having them were too great. From just a National Security perspective, without strict protocols, it would have been remarkably easy to get Covid-19 spreading inside. But what is apparent is that the protocols were not adhered to.

For the rest of us, the lesson is the ultimate cautionary tale. This crisis is on-going. We do not have the opportunity to let our guard down. We have to become our own nagging parents and work out ways of keeping that up. There is room for substantial innovation here and it will be certainly the top of my mind in thinking about how to implement good screening protocols.

What did I miss?