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How US could solve coronavirus testing messExBulletin



Mary Louise Kelly of NPR speaks with Dr Atul Gawande, who writes for The New Yorker, about the problem the United States is facing with coronavirus testing and what can be done to fix it.


A few weeks ago in July, Dr Atul Gawande visited a lab, the Broad Institute – a large university lab affiliated with MIT and Harvard. Gawande was interested in the coronavirus tests, why there is still not enough capacity in the United States, why the results can take so long. And what he saw was quite breathtaking – a lab with the capacity to process up to 35,000 tests per day, the ability to expand that on a few weeks’ notice to 100,000 tests per day. But when Gawande, a doctor from the Mass General Brigham Hospital System, visited, the Broad Institute was only receiving a few thousand samples a day. He saw an entire machine room in slow motion. Gawande writes about this in The New Yorker.

Welcome back. Nice to talk to you again.

ATUL GAWANDE: It’s great to be sure.

KELLY: I started with this story from your article because I was tested this summer, like a lot of people, and found the process incredibly difficult to navigate. It took too long. The idea that there are huge underutilized labs in this country is – the frustrating word is only just beginning to catch on. What’s going on?

GAWANDE: Well, in the beginning we didn’t have enough labs to do tests. We now have dozens of labs that have capacity, and it’s an implementation issue. What I mean by that is we have places that don’t have the operations to connect their testing prowess to the places and people who need it. I compared it to a power grid, right? You may have areas with excess electricity supply and places where there are blackouts. And unless you have the connections between them, they can’t meet the need. So in New England we do well with testing in general, but that supply can’t go where there isn’t proper rotation. We’re dominated in the United States by three, four big commercial labs, and they have the logistics. No. 1, you have to have contracts with all insurers to bill in our kind of crazy, fragmented system. So part of the madness of our screening system is the madness of our health care system. And then the second part is that they have the means of transport to pick up the tubes from everywhere, ship them, the barcode on the samples. All these laboratories available on the market do not have the same capacity. But these three, four labs that dominate, they’re all telling us that if we just rely on them, they won’t have enough capacity for the fall. And so this is the problem that we have to solve.

KELLY: So it’s a bunch of different interconnected pieces that we would need to fix, which makes me question a very optimistic premise you have, which is that we could fix this. We could fix this in a matter of weeks and have the testing capacity we need. Do you think this is really true?

GAWANDE: I’ll give you an example. When I visited the Broad, this institute was doing 3,000 tests a day. Today, they take 60,000 tests a day for colleges, universities, and nursing homes that need testing. And they keep doing it with a turnaround time the next day. I’ve spoken to labs in California, Minnesota, Alabama that have similar levels of capacity but don’t have those interconnects. What did the Broad do? Well for colleges and universities, you don’t need to set up the billing system to be able to get it from insurers. Universities and colleges pay it out of pocket. Broad costs are about a third of current rates. You know, usually the cost of processing a test is around $ 100 plus $ 50 to $ 80 for the logistics around that. They charge $ 35 for the processing of the tests. And I see even lower costs that other labs are willing to integrate if we put these interconnections in place.

KELLY: I mean the areas where you see opportunity. Pooled testing, for example, that is – just to briefly explain, you combine a lot of samples. Like, you put everyone in a dorm. You test all the samples together. If they are negative, you can delete the whole group. If you get a positive result you need to go back and test the individual samples and see who might actually be sick. How promising are pooled testing as a way out of this mess we find ourselves in?

GAWANDE: I think it’s extremely important. I have spoken to a number of nursing homes where they have now been relatively clear. They should continue to test regularly. They may have been negative in the past two or three weeks. And that’s a perfect setup. I spoke to a lab yesterday, for example, where they will take 50 people. It will be a saliva test. You spit into a vial, then they combine all 50 vials into one and run it as a test for the same cost as you would a single person. And that allows you to clear those people, at a much lower cost. And then if the pool is positive, you can analyze the individual samples to see who was actually positive. You know, this is going to become a very valuable approach where infection rates are low but not zero. So you have to find ways to clarify people.

KELLY: What about testing the sewage? You write about a University of Arizona success story on this front.

GAWANDE: Yeah. The University of Arizona did some sewage testing and it turned out that the sewage test detected the virus in the sewage outlet of one of the dorms. They quickly tested the 300+ people in the dormitory and found that there were two active infections and were therefore able to stop an outbreak. I think this approach is going to become very important in places where you have dormitories, people living in nursing homes, group homes, prisons, where you could deploy this sewage analysis capability to screen and pick up when you start to have epidemic, then go to swab test. It could increase our capacity in many ways – and also just the burden of doing these kinds of tests.

KELLY: I mean, it sounds like what you’re saying is there’s no quick fix here. I think we have all accepted that. But it will be this whole landscape of things that must change.

GAWANDE: Yes. But I want to push back. It can happen quickly, and that’s what drives me a little crazy. With a war-torn effort – and right now, you know, we’re on the verge of killing 200,000. It is as bad as any situation of war casualties that we have ever had. There is no reason why we couldn’t make a nationwide dedicated effort to connect these dots and do this work.

KELLY: Can you talk about the sense of urgency you feel? I mean, we keep hearing disastrous warnings about a second wave and flu season almost upon us and that we may be looking for one of the worst falls, worst winters in American history.

GAWANDE: Well, we’re in the worst time. I mean, we’re already experiencing a constant level of death that’s untreated. We urgently need to start bringing this capability online now. We could have avoided the last hundred thousand deaths with early testing capability. The next hundred thousand will occur over the next three to four months. And so, you know, by the time we get to the new year, will we have 300,000 dead? I fear we are doing it simply because we are not relaunching and collectively pulling together a national effort to make these fundamental steps happen.

KELLY: Atul Gawande – he’s a surgeon at Brigham and Women’s Hospital in Boston and editor at The New Yorker.

Dr Gawande, thank you.

GAWANDE: Thank you.

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