Months into the spread of the coronavirus in the United States, widespread diagnostic testing still isn't available, and California offers a sobering view of the dysfunction blocking the way.
It's hard to overstate how uneven the access to critical test kits remains in the nation's largest state. Even as some Southern California counties are opening drive-thru sites to make testing available to any resident who wants it, a rural northern county is testing raw sewage to determine whether the coronavirus has infiltrated its communities.
County to county, city to city — even hospital to hospital within a city — testing capacity varies widely, as does the definition of who qualifies for testing.
Testing deserts, stemming from an overwhelmed supply chain and a disjointed public health system, have hit hardest in California's rural north and in lower-income urban neighborhoods with concentrations of residents who already were struggling to get quality medical care. In the absence of a coordinated federal response, local health departments, hospitals and commercial labs across the state have been competing for the same scarce materials. Whether they are "haves" — or have-nots — is determined largely by how deep their pockets are, their connections to suppliers and how the state is allocating emergency supplies.
Compounding these problems is the lack of a state or federal public health infrastructure empowered to acquire and allocate resources on a grand and equitable scale. Hospitals and health systems where many people go for care are, by design, set up to focus resources on their own patients and workers. Their bureaucracies can't readily adapt to do the community outreach and education that could bring testing to the masses; nor are they set up to do the contact tracing that ensures that people who have been exposed to COVID-19 patients are tested and monitored.
Those roles typically fall to county health departments, which in much of California operate on bare-bones budgets that make it a struggle to contain perennial STD outbreaks, let alone a deadly pandemic.
Over the past two months, the state has triaged one testing disaster after another, but it is finally making headway on making tests more widely available, in part by cutting its own deals for supplies and expanding testing sites in underserved areas, said Dr. Bob Kocher, one of three people on a testing task force convened by California Gov. Gavin Newsom.
But conversations with dozens of local health officials, hospital systems, scientists and elected officials reveal just how complicated a task it will be.
Take Lake County, a recreational mecca just over two hours north of San Francisco. With 65,000 residents, it has had so few testing supplies that officials have resorted to buying swabs on Amazon and pilfering chlamydia testing kits for swabs and the liquid used to transport specimens to labs. Through what the county has cobbled together, it has identified six cases of COVID-19, all found via nurses or volunteers who have gone out looking for patients. "We're basically having to do tea leaves to figure out what's going on," said Dr. Gary Pace, the county's health officer.
He knows the county has community transmission, both from the cases they've identified and because they've started running tests on raw sewage to check for the COVID-19 virus; samples from four treatment plants have come back positive. "It is a way to just get more information because we can't do testing," he said. Unlike the diagnostic kits — which make use of supplies every health department in the country is competing for — the sewage sampling is done pro bono by a technology startup.
While announcing an ambitious program to increase testing last week, Newsom highlighted the rural-urban divide. "One of the big struggles we have had in the last few weeks of this pandemic is getting to rural and remote parts of this state and getting up testing sites and making them available," he said.
Newsom is promising to dramatically increase the level of coronavirus testing, with a focus on rural towns and communities of color. California currently tests about 25,000 people a day but has a strategy to raise that to 60,000 to 80,000 per day. The state has opened the first of 86 pop-up testing sites targeted for areas in need. It is launching a program to train 10,000 workers to serve as temporary disease investigators who can do the contact tracing considered fundamental in stemming the spread of the virus.
Pace said he wrote the governor to ask for one of the pop-up sites. "Statewide, there's a situation where there's not enough testing, and if you're trying to demonstrate progress, the way you do that is numbers," he said. "We are interested in equity, though, and in my view, we need some horizontal coverage instead of just lots of numbers."
In Mendocino County, situated along California's rugged North Coast, officials expressed similar frustration. In late April, a health center on the Round Valley Indian Reservation got a rapid test machine made by Abbott Laboratories, distributed via the Indian Health Service. That same day, a tribal member came in feeling sick. That person tested positive for COVID-19, as did five family members. The county previously had identified just five cases, all linked to travel.
Dr. Noemi Doohan, the Mendocino County public health officer, fears a broader outbreak among the six tribes who live on the reservation. The state since has provided 2,000 test kits for people who live or work around the reservation. Doohan's office will have to hire couriers to drive 2½ hours to a public lab in Sonoma County, which also has limited supplies, to get them processed.
It's every lab — and county — for itself
A mix of commercial and public labs are responsible for testing in California, and supply chain limitations have plagued them all. But those with deeper pockets and stronger commercial relationships have been out-competing counties and public labs with limited resources.
Rural Tulare County, spanning the peaks and foothills of the Sierra Nevada, is home to half a million people. It also has one of the highest per capita death counts of COVID-19 in California. Until recently, the local public lab was the only place in the county that could test for the disease. After borrowing staff from another county, buying additional machines, and suspending testing for most other diseases, they are now able to process 85 tests a day. Officials also can send specimens to commercial labs in other parts of the state, but say days-long turnarounds create bottlenecks for tracking patients and finding contacts.
Monterey County, in the heart of the state's "salad bowl" coastal farming region, has relied on donations — and horse-trading — to meet demand. A local hospital found the expensive materials needed to make a missing reagent and mixed a batch for the public lab, said lab director Donna Ferguson. The hospital also gave the county 1,000 swabs, which Ferguson used to barter with Riverside County for extraction kits.
And through the kindness of strangers, she found a stopgap for limits on another important resource: lab workers.
During an interview with a local public radio station in March, Ferguson mused that if one of the three microbiologists working in her lab got sick, it could be disastrous for the county's ability to process tests. The next day, she got a call from a graduate student at Stanford's nearby Hopkins Marine Station. He'd heard the interview. Could he and his colleagues help? The crew of six graduate students from three universities has been volunteering at the lab since, tripling its capacity to 120 tests a day.
Though the supply chain is a concern for labs of all sizes, manufacturers appear to be prioritizing orders from commercial labs and big health systems over public health labs, said Eric Blanks, chief program officer for the Association of Public Health Laboratories, which represents most of the labs run by public health departments in the nation.
Quest Diagnostics, the medical testing giant headquartered in New Jersey, is running 350,000 coronavirus tests a week in its facilities around the nation. But it is being inundated with samples from across the country, and even as it has worked to ease backlogs, counties and private hospitals are waiting days for results.
Kaiser Permanente says it can test 2,000 to 2,500 people throughout the state each week. Sutter Health, a major provider in Northern California, tests around 650 people each day across its hospitals. CommonSpirit Health, which includes Dignity Health hospitals, says it could process 50,000 samples a week if it had to. As of last week, Stanford had run more than 20,000 tests for Bay Area residents. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
But even the giants don't have unlimited supplies. "It really is the manufacturing lines. They’re the ones that right now are the limiting factor," said Karen Smith, system vice president of laboratory services at CommonSpirit Health.
Moreover, hospitals are not set up to solve the broader issue of statewide disparities in access. They can generally handle the patients sick enough to seek out their ERs. But it hasn't historically been their role to arrange community-wide supplies and testing.
"You're not going to go to an emergency room if you're asymptomatic. That's the last place in the world you want to be right now," said Dr. Omid Bakhtar, medical director for outreach laboratory services at Sharp HealthCare in San Diego. "It's frustrating for me. I have the ability to do more [specimens], but how do I get them?"
Tests but no takers
In pockets around the state, some counties have been able to stabilize their flow of supplies, in some cases because they have more financial means, in others because of their relationships with major hospital systems and research institutions.
With more confidence in their supply chains, Los Angeles and Riverside counties say they are ready to offer testing to any resident. Several other counties, including much of the Bay Area, are asking more people, including workers deemed essential without COVID symptoms, to get tested.
But some counties that have managed to ramp up testing are wrestling with yet another problem: not enough people to test. The reasons are twofold. After weeks of being told they shouldn't go for testing because of shortages, the public seems to be adhering to that message even now that more testing is available. And the public health workforce tasked with locating those in need of testing is depleted.
San Francisco can test 4,300 people each day in its publicly supported labs but was receiving just 500 samples a day as of late April. Los Angeles is testing roughly 10,000 people daily but says it needs to double that to lift the shelter-in-place orders. Its focus in coming weeks is to increase testing among the uninsured and those in at-risk living environments such as homeless encampments and skilled nursing facilities.
Health officials say part of the challenge is they aren't getting the word out to poorer residents and communities of color, even as those same groups are being hit harder by the virus in many cities. In San Francisco, for example, Latino residents make up 16% of the population but 25% of COVID-19 cases. In Los Angeles, black people are 9% of the county's population but represent 15% of the deaths from COVID-19 for which race and ethnicity data is available.
Kocher, of the state testing task force, acknowledged the state has more work to do. But, he argued, there's also a sufficient amount of testing capability available today, especially via high-capacity commercial labs where the state says the vast majority of specimens should be processed.
"Right now, we're concerned with not having enough samples collected," he said.
When officials do slowly begin to let people return to work and school, experts agree that cases will go up, creating even more need for labs, testing and contact tracers. Preparing for that future will require even more resources.
"We need money," said Santa Barbara County Health Officer Dr. Henning Ansorg. "Lots of money. Lots and lots of it."
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.