Health and Healthcare Systems

This is why we should test everyone for COVID-19

Valerie Dominguez, whose results came back negative, is tested for coronavirus disease (COVID-19) at United Memorial Medical Center in Houston, Texas, U.S., December 9, 2020. Picture taken December 9, 2020.

Universal testing is worth trying, even if it only has a 1% chance of success Image: REUTERS/Callaghan O'Hare

Reda Cherif
Senior Economist, IMF
Fuad Hasanov
Senior Economist, IMF
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  • The potential benefits of a universal testing programme far outweigh any downsides.
  • The barriers - such as a lack of expert consensus and the costs involved - can all be overcome.
  • By deploying universal testing, we can avoid a third wave and the devastating consequences that would result.

Many experts have recognized the merits of universal testing for COVID-19, arguing that the benefits outweigh the costs by a huge margin. To cite a few, Paul Romer, a Nobel laureate in economics, Michael Mina, an epidemiologist from Harvard University, the Safra Center for Ethics at Harvard University, our own IMF working paper, and many commentators have argued for a universal testing and isolation policy (TIP) to vanquish the pandemic and reopen economies safely.

It has been shown unambiguously that continuous testing of the population at a relatively high rate – between 10-20% of the population each day – would squash the spread of the virus and prevent any resurgence. A TIP against COVID-19 would help identify infection clusters early and deal with them in a targeted and inexpensive way. This approach would preclude imposing numerous restrictions on economic and social activities, which are extremely costly.

Universal testing would cost about 3% (at $5 per test and 15% population testing rate) of the $3 trillion fiscal support provided by the US in 2020 and less than 1% of the economic and social losses ($16 trillion) incurred during the pandemic. In other words, it would still be worth implementing universal testing even if the chance of success were less than 1%.

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A major difficulty in addressing the challenge of universal testing is that it lies at the confluence of many fields of expertise such as epidemiology, medicine, economics, public health and industrial systems. As a result, there is still no consensus among experts. The arguments levelled against universal testing include potential inefficacies due to many false negatives and people skipping quarantine, the infeasibility of producing so many tests, the need for the regulatory approval of non-diagnostic tests, and potential costs resulting from the production and distribution of tests and quarantines based on false positives. Others argue that it would provide a false sense of security by negating other non-pharmaceutical interventions (NPIs) such as mask-wearing and social distancing, or, that if it fails, it would endanger the public’s trust in other NPIs such as lockdowns.

These hurdles could be overcome and must not preclude experimentation with universal testing, given that it is economically worthwhile even with a 1% chance of success. The downsides of false negatives or quarantine avoidance can be compensated for with a higher rate of testing. The recently developed rapid antigen tests are cheap, scalable and precise, resulting in a much smaller number of false negatives and false positives. Even though these tests are less precise than some other tests used to diagnose the disease, universal testing is not about diagnosing patients; rather, it is about identifying the infected – what we call epidemiological testing. In addition, while other NPIs are still important in a transition period, once the curve is squashed, universal testing would allow lifting all other NPIs and help reopen large swathes of the economy while waiting for the vaccine.

Universal testing has reduced infections and deaths from COVID-19 in US care homes
Universal testing has reduced infections and deaths from COVID-19 in US care homes Image: Johns Hopkins Medicine

Breaking this tug-of-war among experts and experimenting with a universal testing strategy as a hedge against the pandemic require Rooseveltian resolve. This implies foregoing a 'laissez-faire' approach to production and implementing an industrial policy to ramp up the production of tests quickly. State intervention is required to tackle the market failures stemming from demand uncertainty, capacity constraints, coordination failures, externalities and market power. All the bottlenecks along the way, including regulatory approval and the engagement of the private sector in production, need to be cleared. This challenge looks miniscule compared to the goal president Roosevelt put forth before the nation in 1940 when he announced that the US needed to produce more combat airplanes in the next year than it produced cumulatively since the first flight of the Wright brothers in 1903. Three years later, the US was producing more than 50,000 combat airplanes annually, a 30-fold increase from the 1940 level.

Given the high expected economic return of universal testing, a complete reliance on a vaccine against the virus to end the pandemic represents an 'incredible certitude' and ignores the risk-based approach. It is not certain at all when a safe and effective vaccine will be globally available; even worse, a virus mutation could render the newly developed vaccine obsolete. Even if the world had to wait for just a few more months, it would still be economically justified to experiment with universal testing.

Mass testing since the start of November in Liverpool, UK, has seen a sharp decline in new cases
Mass testing since the start of November in Liverpool, UK, has seen a sharp decline in new cases Image: BBC

Policy-makers should first acknowledge that experimenting with a hedging solution is necessary while waiting for the vaccine. It is even more paramount in developing countries as vaccines might reach them much later than advanced countries. Moreover, scaling up universal testing should follow experimentation in phases, which are similar to the development of a vaccine. The first phase would run trials on neighbourhoods and small towns and study existing experiences to select a set of testing technologies to scale up. The MIT and Georgetown University campuses in the US have successfully reopened while keeping outbreaks at bay by testing students and staff twice a week. The second phase would involve selected cities learning from others about the logistics of large-scale testing and isolation. Indeed, China has done this in the cities of Wuhan and Qingdao and successfully contained the outbreaks. Slovakia has embarked on testing most of its 4.5 million citizens within a few weeks, while Liverpool is the pilot city for the UK’s Operation Moonshot universal testing strategy. The third phase would scale it up nationally to make testing routine.

We now need some more Rooseveltian resolve to experiment with testing and the eventual scale up to the national and global level as well as international collaboration to share experiences. Policy-makers, together with the private sector, can provide the necessary resources to make universal testing a reality and avoid the next wave of the pandemic with its incalculable consequences.

The 2017 science fiction TV series Counterpart, in which an identical parallel world is stricken by a pandemic, foretells eerily our current situation of social distancing, mask-wearing, and billboards urging citizens to wash their hands. The parallel world’s persistently depressed economy could become our future if we do not fully hedge against this pandemic now.

The views expressed in this blog are those of the authors and do not necessarily represent the views of the IMF, its Executive Board, or IMF management.

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