Dr. Atul Gawande: Shoddy public health infrastructure is why COVID-19 testing is as 'messed up as a pile of coat hangers'

Problems with COVID-19 testing in the United States boil down to implementation, not technology, Atul Gawande, MD, writes for The New Yorker: "The lunacy of our testing system is the lunacy of our health system in microcosm." 

"As the saying goes, it's as messed up as a pile of coat hangers," writes Dr. Gawande, former CEO of Haven, current professor at Harvard Medical School and surgeon at Brigham and Women's Hospital, both in Boston. 

Any advancements in testing technology will arrive atop dysfunctional, inadequate public health infrastructure, Dr. Gawande says, arguing that the U.S. should instead focus on building healthcare's version of the national electric grid. 

Four companies complete most testing in the U.S. — Quest Diagnostics, LabCorp, BioReference Laboratories and Sonic Healthcare. They are no match alone for the level of large-scale molecular diagnostic testing needed with this pandemic. Results routinely took four-plus days through August, rendering tests essentially useless. Turnaround times improved when testing volumes declined, because many people simply gave up. 

Fortunately, numerous other university-based and independent molecular-diagnostics laboratories have the ability to join the Big Four labs and expand the country's testing capacity, Dr. Gawande writes. The problem is that they don't have the logistical operations to link their supply of tests to the people who need them and to the entities that pay for them.

"Decades ago, electric companies were organized in the same way that laboratory testing is organized today," he writes. "They were vertical monopolies that ran their own power plants, transmission lines and customer operations. That arrangement got the job done, but it meant that many communities endured brownouts and blackouts from a shortage of capacity, while others had an oversupply. And the companies impeded innovation such as cleaner and cheaper energy."

The creation of the national electric grid that physically connected the electricity supply and the Energy Policy Act of 1992 that required transmission line owners to allow electric-generation companies access to their power lines changed the game. Electricity supply increased and balanced, costs were lowered, and alternative energy was produced. 

"We have no national grid for the generation, transmission, or distribution of our testing supply — or, for that matter, the supply of ventilators, masks, intensive care beds, or almost any other healthcare resources," Dr. Gawande writes. "Now we're paying the price. In power generation, the worry is that our national grid is aging; in healthcare, the worry is that we have no grid at all."

He argues that this anemic public health infrastructure is the result of longstanding insufficient funding. Spending per person on medical care reached an estimated $11,600 in 2019. That same year, the average spending per person allocated to state and local health departments was $56. Some health departments today still receive test results by fax and manually enter them into databases, Dr. Gawande notes.

"Public health agencies that are supposed to look after communities' health have been forced to expand tattoo parlor inspections while shrinking their programs to assure adequate maternal and child health services or screen for chronic illnesses like high blood pressure and diabetes," he writes.  

Additionally, public health and healthcare delivery have traditionally been treated as two distinct domains in the U.S. To match testing loads to labs with capacity, that needs to change. 

One American city leading the way in testing is San Francisco, which flexed muscles built from the the HIV/AIDS epidemic. As a result, the city is advanced in its ability to link public health services and medical care, ensuring the two work together. Its CityTest SF network, which includes 31 sites, has accounted for two-thirds of the city's daily volume of tests.

Dr. Gawande co-founded the Assurance Testing Alliance in New England, which has been assembling a logistics grid that links employers, schools, nursing homes and other institutions that need regular testing to those who have the capacity to deliver it. So far the alliance has gotten the total cost of a PCR test down to $50 with a next-day turnaround time. Several governors are attempting a similar approach, forming an interstate compact to buy and distribute the rapid-testing devices and supplies needed for delivery of 5 million tests.

"Such efforts aren't a replacement for national leadership, but they start the work that must be done to make ordinary physical interaction safe again, and to begin creating the public health system we deserve," writes Dr. Gawande, concluding with a line from the late U.S. surgeon general C. Everett Koop, MD. 

"Healthcare is vital to all of us some of the time, but public health is vital to all of us all of the time." 

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