Issue 46: Why we can't test and trace
Countries, like people, do some things well and some things not so well. One thing we have lost is the command and control capacity to do test and trace at scale
Today’s briefing is by Andrew Potter (AP), who is an associate professor at the Max Bell School of Public Policy at McGill University.
1. Dreams of Technocracy
At this stage of the COVID-19 pandemic, it is clear that huge swaths of the United States, as well as Canada’s two biggest and hardest-hit provinces, Ontario and Quebec, have decided to adopt an “open up and hope” approach to ending the lockdown. Maybe it will work, but if it does will be a matter of luck more than any great well-executed strategy.* It’s a far cry from the early days and weeks of the pandemic, when trust in public health expertise was high and it looked like we would be able to science our way out of this.
At the heart of the public health technocratic ambition was the plan to test, trace and isolate. Through mass testing of the population, tracing back the contacts of those who test positive, and isolating the infected, we would be able to contain the virus and keep it from spreading through the general population. In mid-March, the WHO urged everyone to follow the lead of countries like South Korea and Germany and implement strong testing and tracing regimes.
It all seemed pretty straightforward: Do a lot of tests, employ armies of human contact tracers supported up by data from phone-based tracking apps, and put in place rigid isolation regimes with serious penalties for violations. The countries that were able to do it have reaped the rewards of low numbers of cases, a relatively small number of deaths, and early re-openings.
But it soon became clear that it isn’t that straightforward, and many governments (especially state and provincial governments in the US and Canada) struggled to ramp up testing to even a fraction of the levels needed to do contact tracing properly. In fact, Ontario and Quebec are still struggling to hit their provincial testing targets, which is denying the health authorities the data they need to properly fight the coronavirus.
Meanwhile, the United States is currently doing around half a million COVID-19 tests per day, having struggled for months to do even half that. For context, this is still only about half the number of tests the Global Health Institute at Harvard says would be needed to properly implement test and trace. It’s also an order of magnitude shy of the testing levels required by the plan put forward by Paul Romer, who has emerged as probably the most prominent testing advocate in the country.
At first, the struggle to ramp up testing was attributed to supply chain bottlenecks: there weren’t enough swabs, there weren’t enough reagents, there weren’t enough certified labs or trained clinicians. But even as those problems got resolved, and even though politicians have read the riot act to their health officials and the health officials have promised to do better, the testing levels haven’t climbed, and testing and tracing has never been implemented at the necessary scale.
2. Reality bites
At the heart of the problem sits the question of capacity. For whatever reasons, we simply don’t have the state capacity that countries like South Korea, Australia, and Germany have to implement a test and trace regime. But to say it is lack of capacity is not an explanation, it’s a placeholder term for what eventually does the explaining. “Capacity” encompasses everything from leadership to financing to bureaucratic structures to technical abilities to culture. So what it means to say that a government doesn’t have the “capacity” to do something will vary from state to state, and from problem to problem.
But one thing that seems to be happening is that the pandemic is making countries more like themselves. They are like people in this regard: the pandemic is amplifying their weaknesses and forcing them to fall back into their comfort zones, focusing on what they know how to do. And like people, countries specialize, develop areas of expertise or ways of managing problems that reflect their wealth, national character, political culture, and technology.
And so if you look at the list of countries that have done test, trace, and isolate properly, is anyone really surprised that it includes the South Koreans and the Germans and the Australians? These are countries that have retained a high capacity to do command and control at the civilian level -- you only have to visit them even as a casual tourist to see that they are countries that take getting things done seriously.
South Korea: 12 000 cases; 277 deaths; deaths/1million: 5
Canada: 99 000 cases; 8146 deaths; deaths/1million: 215
Australia: 7320 cases; 102 deaths; deaths/1million: 4
USA: 2.1 million cases; 118 000 deaths; deaths/1million: 356
By the same token, is anyone really surprised that the United States and Canada have manifestly failed in this regard? Just look at our airports or our public infrastructure. The problems facing the United States are legion and well-discussed and not worth getting into here, but Canadians like to flatter themselves that they have their act together in a way that the US does not. But the COVID-19 pandemic has exposed Canada as little more than a big federalized public insurance scheme.
A big federalized public insurance scheme is worth having, but if that’s all your country can do it limits your options during a pandemic. Large scale testing and tracing isn’t an insurance program, and can’t be accomplished by simply writing a cheque. It is a matter of logistics: You need the stuff (testing kits, reagents, labs), the technology and equipment, and the trained people. But you also need an organisation with the capacity to coordinate and run the programme. And if you know anything about Canada, the problem becomes immediately obvious: what institution could conceivably do this? What agency or organisation in our society has anything close to the top-down, command and control expertise and the strategic wherewithal to do something like this at anything close to the scale required?
There exists no such institution. For decades, every important measure of authority, legitimacy and capacity to actually do anything has been steadily bled from the federal government to the point where it now has two primary functions: It writes cheques and it cajoles the provinces, who cash the cheques and ignore the cajoling.
To give just one immediate example of the scale of the federal dysfunction: Ottawa would like the country to use a single contact tracing app, but can’t get the provinces to agree, so individual provinces are now rolling out their own apps, which will make national coordination next to impossible. The truth is there simply is no national institutional capacity to do what is required by a large scale testing and tracing programme.
Actually, that’s not quite right: There is one institution that could properly execute a nation-wide test and trace campaign, and that’s the Canadian Armed Forces. The CAF has the authority, the technical expertise, the command-and-control mechanisms, and the mission-first culture that is required. It is Canada’s foremost get-stuff-done institution. Unfortunately, the bulk of the military’s resources during the pandemic have been deployed to long term care facilities in Ontario and Quebec, doing a lot of menial work to replace the staff that either got sick or simply decided it was not safe to go to work. (AP)
* I’ve not discussed the example of British Columbia here, which is Canada’s singular test and trace success story. It’s chief public health officer Bonnie Henry gives a good account of their strategy here.
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