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How The U.S. Could Solve The Coronavirus Test Mess


A few weeks back, July, Dr. Atul Gawande went to see a lab, the Broad Institute - big academic lab affiliated with MIT and Harvard. Gawande was interested in coronavirus testing, why there is still not enough capacity in the U.S., why results can take so long. And what he saw was pretty mind-blowing - a lab with the capacity to process up to 35,000 tests a day, the capacity to expand that given a few weeks' notice to a hundred thousand tests per day. But when Gawande, a doctor in the Mass General Brigham hospital system, visited, the Broad Institute was receiving just a few thousand test specimens per day. He saw a whole room of machines standing by idle. Gawande writes about this in The New Yorker.

Welcome back. Good to speak with you again.

ATUL GAWANDE: It's great to be on.

KELLY: I opened with that story from your piece because I got tested this summer, like a lot of people, and I found the process incredibly hard to navigate. It took too long. The idea that there are huge labs sitting around underutilized in this country is - the word frustrating hardly even begins to capture it. What is going on?

GAWANDE: Well, early on, we didn't have enough labs that had testing up and running. We now have scores of labs that have capacity, and it's an implementation problem. What I mean by that is that we have places that don't have the operations to connect their testing prowess to the places and the people that need it. I compared it to an electric grid, right? You can have areas where there is an oversupply of electricity and places that are having blackouts. And unless you have the connections between them, they can't meet the need. So in New England, we're doing well with testing in general, but that supply can't be brought to the places where there isn't adequate turnaround. 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 the insurers to bill in our kind of crazy, fragmented system. So part of the lunacy of our testing system is the lunacy of our health care system. And then the second part is they've got the transportation to pick up the tubes from all over the place, ship them, the bar coding onto the specimens. All of these labs that are available out there, they don't have that same capacity. But those three, four labs that are dominating, they're all telling us that if we're relying on just them, they're not going to have enough capacity for the fall. And so this is the problem 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 within weeks and have the testing capacity that we need. Do you think that's really true?

GAWANDE: I'll give you an example. When I visited the Broad, that institute was doing 3,000 tests a day. Today, they hit 60,000 tests per day supporting colleges, universities, nursing homes that need testing. And they're continuing to do it with a next-day turnaround time. I have spoken to labs in California, in Minnesota, in Alabama that are bringing on similar levels of capacity but don't have those interconnections. What did the Broad do? Well, for colleges and universities, you don't have to set up the billing system so that you can get it from the insurers. The universities and colleges are paying for it out of their own pocket. The Broad's costs are about a third of what the current going rates are. You know, usually the cost of processing a test is about $100 plus $50 to $80 for the logistics around that. They're charging $35 for test processing. And I'm seeing even lower costs that the other labs are willing to bring onboard if we make these interconnections come into place.

KELLY: I want to talk through areas where you see possibilities. Pooled testing, for example, this is - just to explain briefly, you combine a large number of samples. Like, you get everybody in one dorm. You test all the samples together. If they come out negative, you can clear the whole group. If you turn up a positive, then you need to go back and test the individual samples and see who actually might be sick. How much promise do you see in pooled testing as one way out of this mess we're in?

GAWANDE: I think it's hugely important. I've talked to a number of nursing homes where now they've been relatively clear. They need to keep testing on a regular basis. They might have been negative for the last two or three weeks. And that's a perfect setup. I spoke to one laboratory just yesterday, for example, where they will take 50 people. It'll be a saliva test. You spit into a vial, and then they combine the 50 vials into one and run it as one test for the same cost as you would run for a single person. And that allows you to clear those people, have a much lower cost. And then if the pool tests positive, then you can run the individual samples to see who was actually positive. You know, that's going to become a high-value approach in places where the infection rates are low but not zero. So you need to find ways to clear people.

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

GAWANDE: Yeah. University of Arizona has been doing sewage testing, and it turned out that the sewage test picked up virus in the wastewater outflow from one of the dormitories. They quickly tested all 300-plus people in the dorm and found there were two active infections and therefore were 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, congregate living group homes, jails, where you could be deploying that wastewater testing capability to screen and then pick up when you start to have an outbreak and then go to the swab testing. That could increase our capacity in lots of ways - and also just the burden of doing these kinds of tests.

KELLY: I mean, it sounds like what you're saying is that there's no quick fix here. I think we've all come to terms with that. But it's going to be this whole landscape of things that needs to get changed.

GAWANDE: Yes. But I want to push back. This can happen quickly, and this is what drives me a little bit crazy. With a war footing effort - and right now, you know, we're at the point of about to have 200,000 deaths. This is as big as any war casualty situation we've ever had. There is no reason we could not be deploying on a national scale the dedicated effort to connect these dots and make this work.

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

GAWANDE: Well, we're in the worst time. I mean, we already are experiencing a steady level of death that is not being dealt with. It is urgent that we now start to bring this capacity online. We could have avoided the last hundred thousand deaths with an early testing capability. The next hundred thousand will happen 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 deaths? I fear we will simply because we're not picking up and collectively pulling together a national effort to make these basic steps happen.

KELLY: Atul Gawande - he's a surgeon at Brigham and Women's Hospital in Boston and a staff writer at The New Yorker.

Dr. Gawande, thank you.

GAWANDE: Thank you. Transcript provided by NPR, Copyright NPR.

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