The other night, I had a patient in the ER where I work come in with fever, cough and shortness of breath. It would have been a routine visit, if not for the novel coronavirus currently sweeping the globe. The patient was concerned about the virus, and so were we. She had recently traveled to a conference in a country with known cases of COVID-19, as the disease caused by the coronavirus is called. She was middle-aged and had HIV, which we worried could increase her risk of serious illness from the virus. We contacted the department of health, where all testing in my state is currently performed, to request permission to test for the coronavirus.
The verdict? Denied.
Since the patient did not require hospital resources, like an oxygen mask or IV fluids, we discharged her home, urging her to self-quarantine and return if her symptoms worsened.
Every ER doctor that I work with already has several stories like this. This week, in Massachusetts, testing has been permitted only for patients with respiratory symptoms requiring hospitalization, or for patients with such symptoms who have traveled to endemic areas or had contact with confirmed coronavirus cases. Similar criteria apply in other states. The problem with this approach is that, according to all indicators, it is almost certainly missing a large number of cases.
Strong evidence suggests that the coronavirus is already spreading within the community and has been for weeks. After the first confirmed case appeared in the United States on Jan. 20, scientists in Seattle who had been collecting swabs to study influenza went rogue and, against the directive of the Food and Drug Administration and Centers for Disease Control and Prevention, developed a test and began looking for coronavirus in their flu samples. In late February, they quickly found their first positive — a teenager with no recent travel and no sick contacts. Genetic sequencing of the virus by the same researchers suggested that the virus had likely been circulating in the community for as long as six weeks.
Now cases with no recent travel and no known contacts are emerging everywhere. Earlier this week, public health experts from Johns Hopkins confirmed that the virus is likely spreading undetected in the community. Put another way, this thing is probably out of the barn.
If that's the case, then why are we still facing such strict limitations on who we can test? There isn't a clear answer, but it seems to be a function of a woefully inadequate supply of test kits. In other words, what few tests we do have are being rationed for the people who need them most, like those requiring hospital admission. While South Korea has run nearly 250,000 tests and has capacity to test 10,000 people per day, current suggest the United States has performed only about 19,000 tests. Here's another way to express just how far behind we are in terms of testing — as of March 11, the United States had performed only 23 tests per million people, while the U.K had performed 347 per million, Italy 826 per million, and South Korea 3,692 per million, according to an analysis by multiple media outlets and the .
Ashish Jha, director of the Harvard Global Health Institute, told NPR on Thursday that the United States' response has been "much, much worse than almost any other country that's been affected." He reached for words like "stunning," "fiasco" and "mind-blowing" to describe the situation.
This leads to a second, much more important question — how were we so staggeringly unprepared to test for this virus? A number of hiccups have contributed. First, many test kits released by the CDC on Feb. 4 were defective. Designing and manufacturing these tests is challenging, and sometimes problems arise. There have been reports that early Chinese tests may have had a false negative rate as high as 50%. But rather than encourage university labs and private companies to help with test development, the FDA withheld permission for such work until Feb. 29. Contrast this with the response in South Korea, where a private biotechnology company began developing a test on Jan. 16, had a working version ready by Feb. 5t and had government approval for use one week later. That company is manufacturing enough kits to test a million people per week.
Private companies and academic labs are now developing their own tests. The Cleveland Clinic recently announced it had developed a rapid test for the virus. But concerns are mounting about a shortage of critical materials needed to run these tests.
The total failure to ensure that adequate testing would be available will likely prove to be the single most important factor in why the United States has been unable to contain the outbreak. Aspreviously reported by NPR, Hong Kong, Singapore and South Korea all deployed an aggressive testing strategy very early on. This allowed them to find the first few cases and isolate them, preventing unchecked community spread. Because our government and public health authorities were unprepared, we have missed that precious opportunity in the United States, and it is going to cost people their lives.
This failure represents a profound abdication, at the highest levels of government, of responsibility to the health and security of the American population generally and of more vulnerable populations especially. Public health experts have known of the exceptional risk posed by novel coronaviruses for more than 20 years, but the current administration limited funding to the CDC and disbanded a White House unit expressly dedicated to preparing for a pandemic just like this one. Public statements from the top echelons of our government — false comparisons to seasonal influenza, wildly misleading promises about access to testing, reassurances that everything is "perfect" — continue to seed confusion and erode trust.
The most stunning illustration of this radical failure of leadership and responsibility occurred, for me, Thursday morning on C-SPAN. CDC Director Robert Redfield was testifying in front of Congress, and Rep. Debbie Wasserman Schultz was asking who was responsible for ensuring that those who needed to be tested could be tested. After several attempts to dodge the question, Redfield fell silent. He had no answer. He stared down at his desk, before slowly turning to a man seated next to him. It was Anthony Fauci, director of infectious diseases at the NIH. He had the courage to say what Redfield wouldn't.
"The system is not geared to what we need right now," he said. "And that is a failing."
What do we do now? We should still emphasize scaling up testing capacity in a massive way. Knowing exactly who has the disease will enable more effective quarantines, protect vulnerable populations and mitigate community spread. But the most critical measures occur at the individual level. Everyone should practice social distancing. That means curtailing all social interaction, canceling organized gatherings, working remotely, switching elbow bumps for handshakes and keeping a distance of several feet from others whenever possible. Everyone should also practice obsessive hand hygiene. That means washing your hands with soap and water for 20 seconds on a regular basis, and every time you come into contact with high-traffic areas, like a doorknob or subway pole. Avoid touching your face for any reason — use a tissue to scratch an itch.
If you have any cold or flu-like symptoms, like fever, sore throat, cough, or muscle aches, you should wear a mask if you have access to one, isolate yourself, keep washing your hands and avoid contact with others as much as possible until at least two to three days after your symptoms have resolved. If you develop difficulty breathing, chest pain, profound weakness or confusion, then it's time to seek medical attention.
Community spread in the United States is already occurring, and the virus will likely reach a large number of people. But this is not the nightmare scenario. The nightmare scenario occurs if lots of people get sick at the same time. This could lead to a massive surge of ill patients arriving at hospitals all at once, which could easily overwhelm resources like oxygen tanks, ventilators and intensive care unit beds. If this happens, then people will die who otherwise might have recovered. Some European countries are already facing a situation like this. It is imperative that we spread out infections over time, or flatten the curve. This way hospitals will have adequate resources to treat everyone, and won't become overwhelmed. How do we flatten the curve? All of the individual actions I described above.
We're all in this together. If everyone does their part in limiting further spread, lives will be saved.
Clayton Dalton is a resident physician at Massachusetts General Hospital in Boston.
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