Scaling ain't cheap or easy

We want rapid and frequent testing but we need to be mindful of constraints

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.

Being able to have frequent testing for Covid-19 is the only current option to restore economic and social life to something close to normal prior to full vaccine distribution (which will likely take a year or more). Many commentators, pushing for urgency, have suggested that getting to scale would be relatively easy. In the US, Congress allocated many billions of dollars for testing yet there are still shortages. This is likely due to it not being a priority or worse. But a recent interview with the person in charge, Admiral Brett Giroir, yielded some further considerations.

KELLY: And you are preaching a message that absolutely has been underscored, supported and that public health officials would 100% agree with - wear a mask. Socially distance. Do all of those things. But I have been interviewing those same public health officials for months and months and months now. They argue that, you know, to put this pandemic behind us, to keep the country and the economy safely reopened, you need to be doing tens of millions of tests every day. What is preventing us from doing that?

GIROIR: That is a physical impossibility. We do not...


GIROIR: Why - is that - sort of an existential question, right? You know, why can't people fly? Why can't these things happen? I mean, we have invested every single dollar that's possible into increasing the testing infrastructure. Remember, we only had a few thousand tests we could do a week. Now we're doing over 10 million per week. We have point-of-care tests, but we do not have the physical capability to actually have tens of millions of tests.

The closest one is Binax, right? That's the closest one. That's $5 a test. It's very easy to administer. We are ramping from 30 to 35 to 50 million per month, but that's per month. There are not a world supply of the certain types of material that goes into that. We are doubling, tripling the swabs that are being made. It's - it is no lack of will or money or infrastructure. But we're going from a standing start to where we are today, which is an unprecedented rise. I would love for us to have hundreds of millions of tests per month. There has been no lack of investment, effort, science, coordination. It's just we're not there yet as a country.

KELLY: So you're saying this is not a shortage of will. This is not a shortage of money. There are physical just manufacturing impediments to this.

GIROIR: There are physical manufacturing impediments that can't be fixed overnight. A lot of them could be fixed over weeks. We went from being able to make a few million swabs a month to a hundred million or so per month. We had no point-of-care tests - none...

Now there is lots going on here. Critics are correct, if countries got their acts together 8 months ago, whatever issues in supply there are could have been resolved. But the fact of the matter is that most countries did not. They pushed dollars towards traditional PCR tests but did nothing to promote rapid tests. There will be much discussion as to why. But that is not my concern here. What if we did pivot and want to do this now? What real challenges would we face?

Military Operation

As I have written before, Slovakia shows how testing can be done at a national level. China did the same thing in several cities at an even larger scale. With China, there was enforcement backing it up. In Slovakia, it was incentives. But in each case, it is part of a big push effort to turn infections around. In the Chinese case, it was enough to get back to normal. In Slovakia, we will still see.

To achieve a big push, you need to get sufficient tests and then pour resources into quick distribution. In both these cases, this was done. So there is sufficient supply for big pushes at least when they are done in, relatively, isolated cases. But this is also of the order to 5 to 10 million people. That is very different from hundreds of millions of people.

The Campus Solution

Rather than have a once-off push, there are places where testing has been integrated into life. As I have also written about before, the University of Illinois tests its entire population several times per week and has been able to achieve some normality as a result. But we have to be mindful of what it took to get to this point.

  • A geographically contained space where the people do not stray far from the centre;

  • A mobile population who can be relied upon to be passing testing places regularly;

  • An on-campus infrastructure to store and process tests;

  • An IT infrastructure to record test results;

  • A complementary set of sanctions that can ensure behaviour.

In these cases, there was a lot of self-provision in the solution and capability/will to do it. And it is far from universally pursued even in campus environments.

Preparing for Scale

There is a big difference between operating at scale when you have prepared already to do that versus operating at scale when there are no such preparations.

As a case in point, consider Germany’s attempt to roll out rapid antigen testing to long-term care facilities. This article describes what they are trying to do. The goal is to test everyone a couple of times per week.

The requirements to be able to do so are described here:

To be able to test residents and others, and receive compensation, care homes are required to produce a ‘testing concept’. This involves defining the groups to be tested; the frequency of testing; the processes involved in administering tests (including the procurement of the tests, training requirements, the need for personal protective equipment); and a definition of cases in which an antigen test should be replaced by a PCR test (see example). Care homes have to procure the testing kits themselves. Tests have to meet a set of minimum requirements set out by the Paul Ehrlich Institute and the Federal Office for Pharmaceuticals and Medical Products has published a list of tests available in the market that meet these minimum standards.

The home’s testing concept has to be approved by the local health authority in its area, as a condition of reimbursement. Care homes are eligible to receive 7 Euro per test if they procure the test themselves, for up to 20 tests per resident per month, covering all testing requirements of staff, residents and visitors. Care homes can receive funding for a larger number of tests, if this has been approved by the local health authority as part of the testing concept. Reimbursement is organised through regional associations of office-based doctors (Kassenärztliche Vereinigungen); these organisations routinely organise the reimbursement of services provided by office-based doctors to patients under social health insurance.

You might look at this and roll your eyes at the requirements because they are requirements. But, in reality, they are the bare minimum. Basically, it says you have to know what you are doing, who is going to do it, what protections they need and you have to procure the testing kits. There are some general guidelines but how you practically do this within any particular home still requires work. It doesn’t take long for real challenges to kick in.

Care homes need to develop their own testing concept, which is time consuming for both the homes and the local health authorities required to review and approve them. Again, larger organisations such as the Arbeiter-Samariter Bund or Caritas that operate a large number of homes, may have an advantage over smaller entities with less capacity to allocate resources to develop concepts. There have also been reports of local authorities struggling to approve testing concepts at pace, with the city of Bremen bringing in the Medical Service of Social Insurance (MDK) to help.

The testing itself can be done quickly if considering a single test, but doing hundred or thousands of them per week require substantial addition staffing and resource. Testing also requires appropriate documentation, which also draws on tight resources. Some care homes have managed to employ additional staff to conduct the testing; however others reported that they have not been able to employ more staff and that existing staff is already too stretched to engage in additional tasks. There is a general shortage of care personnel in Germany, in both health and long-term care, so it is unlikely that supply will easily match demand. While staff administering tests do not have to be fully medically trained, bespoke training needs to be in place if no medically trained staff is available.

There isn’t much slack in the system to do this. And all this preparation are just fixed costs before you even get to on-going operational challenges let alone market constraints on getting tests. Even for staff, getting in and out is going to probably add 30 minutes to your day and someone has to pay for that.

When I read about this what hits me is how little has been done to prepare to get to scale. To envision rolling out economy-wide, frequent testing is one thing. To develop protocols, standard operating procedures, IT infrastructure, let alone actually trial these things and develop best practices that are intensely valuable at scale are things that will take time. You might be able to procure tests within weeks, but the process of how to move to a testing economy will likely take months to develop.

Parallel Development

With vaccines, we realised that we had to take steps that were normally done in sequence — like evaluation and manufacturing — and do them in parallel. With at-scale testing, we have to think the same way. It does us no good to lament the slow process of getting tests approved and the time it takes to procure supplies without at the same time doing the heavy work required to prepare for distribution at scale. Governments need to be pushing for this work to be done right now and not wait until everyone has decided and jumped through the hoops to make rapid testing a policy priority. The in-coming Biden government claims to be supporting rapid testing at scale. If so, where is the work to prepare the US in how it can be done?

What did I miss?