America Is Testing For COVID-19 More Than Ever — And It Still Isn’t Enough

Expert consensus was clear early in the pandemic: To control the spread of COVID-19, the U.S. needed to increase testing. Four months on, we are testing more — a lot more. The number of Americans getting tested daily is higher than at any point in this pandemic, and we’re testing more people per capita than almost any other country on the planet.

Yet many experts say we still need more tests.

Despite a steady increase in testing infrastructure, the U.S. is caught in a vicious cycle with no end in sight. A lag in testing leads to more cases, which leads to the need for even more tests to finally get a handle on the pandemic. We’ve been playing catch up from the beginning, and, experts say, we’re still not close to closing the gap in most states.

In early May, for example, a group of researchers at the Harvard Global Health Institute calculated the average daily number of tests each state and Washington, D.C., would need to conduct in order to begin reopening later that month. At the end of June, the researchers adjusted those numbers.1 In 18 states and D.C., the June testing goals for mitigating the pandemic were lower than the goals first proposed in May since the pandemic had waned there. But in the rest of the country, the testing goals were higher. Of these 32 states with higher testing goals in June, just six had an average daily testing rate last month that met the goal, and 13 still didn’t have an average daily testing rate that met the May benchmarks.

The majority of states and U.S. are lagging behind in testing

The difference in the average number of tests and the Harvard Global Health Institute’s mitigation testing goal for each state, D.C. and the country

Hawaii 771 192 +301%
Vermont 1,060 265 +300%
Alaska 2,016 520 +288%
Montana 1,702 553 +208%
New Jersey 22,541 7,346 +207%
West Virginia 2,471 923 +168%
Connecticut 7,212 2,769 +160%
New York 61,704 29,591 +109%
D.C. 1,694 1,002 +69%
Maine 1,511 952 +59%
Delaware 1,674 1,268 +32%
Illinois 23,525 19,116 +23%
Massachusetts 8,510 7,333 +16%
South Dakota 1,199 1,041 +15%
Idaho 1,420 1,363 +4%
Rhode Island 2,926 2,893 +1%
North Dakota 1,136 1,129 +1%
New Hampshire 1,601 1,622 -1%
Maryland 7,799 8,292 -6%
Indiana 7,422 8,051 -8%
Michigan 13,810 15,646 -12%
Oklahoma 4,946 5,816 -15%
Nebraska 2,567 3,133 -18%
Wyoming 309 394 -21%
Pennsylvania 10,284 13,326 -23%
Kansas 2,726 3,574 -24%
New Mexico 4,776 7,044 -32%
Louisiana 11,780 17,896 -34%
Minnesota 10,729 17,361 -38%
Oregon 3,614 6,152 -41%
Kentucky 5,239 9,523 -45%
Wisconsin 10,018 19,196 -48%
Iowa 4,930 9,497 -48%
Virginia 10,988 22,422 -51%
Nevada 4,500 9,518 -53%
Missouri 5,982 13,007 -54%
United States 509,782 1,165,199 -56%
Washington 7,003 16,062 -56%
Tennessee 11,905 27,894 -57%
Ohio 13,234 35,148 -62%
Colorado 4,774 12,979 -63%
Arkansas 6,056 16,668 -64%
Utah 4,228 11,710 -64%
California 74,076 222,862 -67%
North Carolina 16,458 51,305 -68%
Texas 30,581 117,119 -74%
Florida 30,788 142,300 -78%
Georgia 12,278 64,048 -81%
South Carolina 6,012 32,831 -82%
Alabama 6,303 41,577 -85%
Arizona 10,238 74,135 -86%
Mississippi 3,857 28,835 -87%

* These 16 states report the number of specimens tested, not people, in their testing reports. Because some people may be tested more than once, these numbers are probably higher than the number of people tested. Texas reports a mix of specimens and people tested. Wyoming switched from reporting data on specimens tested to people on June 19.

The Idaho Department of Health and Welfare includes a small number of out-of-state residents among its counts.

Source: the covid tracking project, Harvard global health institute

“We are finally hitting the numbers that we needed to hit in March, but it’s July,” said Dr. Thomas Tsai, a surgeon and researcher at Harvard who co-authored the testing analysis. “And in that interim, hundreds of thousands of new cases have erupted.”

There are lots of factors that have likely contributed to the fact that the U.S.’s COVID-19 case numbers haven’t dropped the way other countries’ have. But a lack of sufficient testing has made it that much harder to implement any strategy that might help the country overcome those factors. Take contact tracing, for example, a strategy deployed in South Korea early in the pandemic with great success. Ideally, whenever someone tests positive for COVID-19, they’d isolate themselves, and public health workers would contact everyone that person had contact with recently and test them for COVID-19 too. If any of those people test positive, they isolate themselves, and then their recent contacts are tested. None of this is possible without testing.

The Harvard testing goals aren’t meant to encourage us to just randomly test 1.2 million Americans every day and hope the virus disappears. The idea is that if we were sufficiently testing to track, trace and isolate positive cases, we’d be seeing daily testing numbers closer to 1.2 million, instead of 600,000.2

“I do not want to overstate the kind of magical nature of testing,” said Dr. Ashish Jha, director of the Harvard Global Health Institute, during an online press conference. “The lack of testing makes it difficult to control the virus, but even if you have adequate capacity, even if you have deployed it effectively, you’ve got to do something with that.”

The shortfall in testing numbers is due to two pervasive but opposite problems. First, some labs and clinics have a shortage of supplies and a backlog of tests, sometimes running out of tests five minutes after opening, according to a report in The New York Times, other times causing a wait of seven days or more to get test results. That’s partly the result of the country’s original missteps when it comes to testing, including the Centers for Disease Control and Prevention originally manufacturing faulty tests, and a general lack of preparedness for an epidemic, from which we never fully recovered.

The second problem speaks to a deeper, more psychological issue. Many states have the capacity for more testing, but people just aren’t lining up to get tested, and contact tracers have reported difficulty getting in touch with individuals who have crossed paths with someone who later tested positive for COVID-19. Dr. Michael Hochman, a professor of clinical medicine at the University of Southern California, said this might be due to a sense of fatigue about the pandemic. “At a certain point, you get tested once or twice — I see this with my patients, they’re like ‘oh, this was a waste of time,’” Hochman said. “In the beginning, my patients were calling me asking to get tested. Those calls aren’t coming in anymore.”

There are also other factors that discourage people from getting tested, including costs (while tests are free, the appointment needed to get a test often isn’t), concerns about missing work, or even local limitations on who is allowed to get tested.

All of this still means we have a lack of testing, but not necessarily for a lack of trying.

The U.S. had an opportunity to close the testing gap. During lockdown, strict social distancing helped case numbers drop and lessened the strain on health care systems. As soon as states ease restrictions and begin to allow businesses to reopen, cases are bound to rise. But if, during lockdown, states had ramped up testing dramatically by creating a strong supply chain and expanding testing parameters beyond actively sick individuals,, they would have had the necessary infrastructure to address future rises in cases, according to Tsai.

Instead, states gradually increased testing while simultaneously lifting restrictions, a double-whammy that all but guaranteed the surge in cases we’re seeing now, with little ability to nip local outbreaks in the bud.

Think of it like a forest fire (an analogy a few experts have been using). If you have a handful of small brush fires, you can find them and control them. If you don’t know they’re there, they can quickly turn into a raging forest fire that is much harder to control. Without sufficient testing when cases are low, those cases can go undetected, possibly by people who have mild or no symptoms and are out in the community spreading the disease to more people. This becomes an even higher risk as cities and states start to reopen.

“It’s going to be tough right now because the case numbers are so high that to do really efficient testing, tracing, and isolation, we’re going to need a whole lot of tests,” said Tara Smith, an epidemiologist at Kent State University.

There are some experts who argue we don’t need to dramatically increase testing further, such as Hochman, who has written on the topic. Hochman argues the current level of testing should be sufficient to inform public health responses. But the problem is we’re not executing those responses well, either.

“Masks, social distancing and hygiene are the three things that make the biggest difference, and testing is probably four or five on that list,” Hochman said.

Testing on its own doesn’t equal success in the battle against the novel coronavirus. But for the U.S., our failure to sufficiently test enough people is representative of the many challenges we face.