More Testing Less Freedom

President Biden unveiled a new COVID initiative in a press conference this week.  In addition to more COVID vaccinations, he promised more COVID testing.  This is a bad idea which will create more fear and less freedom.  Testing plays an important role in medical decision making, but indiscriminate testing can lead to harm.  To be beneficial, the right test must be selected at the right time for the right reason.  Let’s compare Biden’s testing plan against these three pillars of laboratory medicine.

The right test.  The President promised free at-home tests.  Although his speech was short on details, I think it is safe to assume he is talking about antigen tests which work much like at-home pregnancy tests.  Antigen tests are fraught with technical and interpretative challenges, making it difficult to separate signal from noise.  The result of increased antigen testing will necessarily be an increase in positive test results, many of which will be false positives.  By contrast, PCR tests do a much better job of separating signal from noise.  Although PCR test results are often misinterpreted, they have far fewer analytic false positives.  President Biden’s plan increases availability of the wrong test. 

The right time.  There is no test for COVID-19, so the President’s call for increased “COVID” testing is technically incorrect.  COVID-19 is a disease caused by SARS-CoV-2 infection.  To have COVID-19, you must be infected by SARS-CoV-2 at the same time you have symptoms of a respiratory infection.  Symptoms without SARS-CoV-2 infection is not COVID-19; SARS-CoV-2 infection without symptoms is not COVID-19. Why does this semantic detail matter?  Because test timing is crucial to the diagnosis of COVID-19.  

Test too early and an infectious person may have a negative result.  Test too late and a person who is no longer infectious may have a positive result, no matter the quality of the test.  This happens with PCR tests and antigen tests alike.  Just like there is no morning-after pregnancy test, there is also no morning-after SARS-CoV-2 exposure test.  Indiscriminate testing will lead to the wrong people isolating.  There will be individuals who consider themselves safe because of a negative test result, and there will be individuals who disengage from society because of a positive test result.  Both groups will be wrong because they test at the wrong time.

The right reason.  Test results should drive actions; there is no other reason for testing.  You should never test for curiosity, because you can, or to confirm a hunch.  This is a testing trap that ensnares many of my clinical colleagues.  By his call for “more testing,” it appears to have ensnared the President also.  Before a test is performed, there must be a clear, distinct plan of action for each possible test outcome.  If the actions are the same, the test should not be performed.  The indiscriminate testing proposed will be used for the administration’s “vaccinate-or-test” plan.  This is the wrong reason.

Vaccinate-or-test.  In his press conference, President Biden reiterated his “vaccinate-or-test” plan to control social intercourse.  His plan will fail to control viral spread since both of the plan’s foundational assumptions are false.  The first assumption is that vaccinated individuals cannot spread infection, but it should be clear to everyone now that this is false.  The second assumption is that individuals who test negative for SARS-CoV-2 cannot spread infection, but since the President proposes the wrong tests at the wrong time for the wrong reasons, this assumption is also false.  

What will really happen because of the increased indiscriminate testing mandated by the President’s plan?

More Tests Less Freedom.  When the wrong test is performed at the wrong time for the wrong reason, the absolute number of positive results will increase.  Even though some of these positive results will be false and many will be insignificant, all these results will be counted as COVID “cases.”  This is because early in the pandemic, the CDC changed its definition of a COVID-19 “case” from positive test and symptoms to positive test or symptoms.  This “case” spike will be raised as a pitchfork to incite fear among Americans, and fearful people are more likely to turn loose of their liberty.  Think I’m wrong?  Consider this statement made by the President during his press conference:

And again, to folks who are not vaccinated: You may think you’re putting only yourself at risk, but it’s your choice.  Your choice is not just a choice about you; it affects other people.  You’re putting other people at risk — your loved ones, your friends, neighbors, strangers you run into.  And your choice can be the difference between life or death.

Joe Biden, December 21, 2021

See where this is going?  “Vaccinate-or-test” will morph into a “vaccinate-or-isolate.”  More testing will result in less freedom and more discrimination.  

A Better Way.  There is another way.  If you feel sick, stay home.  Find a doctor who will give you early treatment for COVID-19, and test as directed by your doctor.  If early treatment doesn’t work, seek higher care at a hospital.  When you feel better, go back to your life.  Wear a mask for a while if you are concerned about infecting others.  These are all commonsense rules taught to us by our parents and used for generations. 

Never let test results make you afraid enough to let go of your freedoms.