Medical Examiner

What the President Has Never Understood About COVID Testing

A protective bubble requires more than wishful thinking.

Donald Trump looks at Amy Coney Barrett as he nominates her to serve on the Supreme Court.
Donald Trump looks at Amy Coney Barrett as he nominates her to serve on the Supreme Court. Chip Somodevilla/Getty Images

Over the past three days, Donald Trump’s coronavirus infection has become the most visible and defining case study in the American experience of the pandemic. It has recentered the virus as the most interesting story in the world. We watch his medical team give announcements and parse its statements for holes. (There are many.) News organizations have started their own attempts at contact tracing whom else the president might have infected, using photographs of him indoors, maskless, and in close proximity to others, because the White House has decided not to bother. Republican senators and top aides and White House staff and pool reporters announce positive test results and isolate themselves or preemptively check into the hospital.

The cascade of cases carries an unavoidable sense of Greek tragedy, of characters finally being dragged down by their own heedlessness. For months, everyone has watched Donald Trump and the people in his orbit reject all the proper precautions against a highly contagious and deadly disease. The president refuses to wear a mask, is uninterested in distancing, continues to hold crowded rallies despite public health warnings against it. Last week, at the start of the presidential debate, we watched his children enter the debate hall, reach their socially distanced seats, and quickly remove their face coverings, in defiance of the explicit instructions of the doctors at the Cleveland Clinic.

The president has justified this bad behavior on the grounds that the virus cannot reach him because he is tested for it all the time and everyone around him is tested all the time too. This constant, abundant testing has been an infuriating or demoralizing counterpoint to the general public’s experience of the pandemic, in which testing has been impossible to get at crucial moments, or hopelessly inconvenient, or so delayed as to be useless. While the president boasted of his surety, the broader population was left to wonder, especially in the early weeks of uncontrolled spread, if their sicknesses were COVID or something else, and whether it was worth the risk and effort to try to find out.

Now the presidential health crisis has demonstrated why this strategy was not only insulting but practically useless. On Friday, the New York Times reported that some of the tests the White House was using weren’t even intended to be used as the sort of coronavirus-get-out-of-jail-free card that they were taken to be. Abbott’s ID Now test, which the White House used, is meant to test sick people who are within the first seven days of symptoms, rather than to screen healthy-seeming people to find out who may be carrying the virus. For people who are infected but not yet symptomatic, the ID Now test is much less accurate, missing around 1 in 3 cases. This follows a study published in the spring that suggested that same test missed 48 percent of positive cases.

But not only was the White House using the wrong test; it was relying on it for a degree of protection that even proper testing wouldn’t have provided. As many public health experts and epidemiologists have said, the best testing we have, used as intended, remains imperfect. There’s still low-level inaccuracy and a tendency to miss infection in the early stages, which is why public health officials insist that masks and distancing be used alongside testing.

This means there’s a category error behind the White House using testing as its only strategy for staying safe. As access to tests has spread, many people have started thinking of testing as a means of occasional “assurance”—an additional piece of information that allows people to proceed with their lives with a little less fear of spreading the virus, perhaps letting them visit an older relative or someone else they really don’t want to get sick. These are limited, individual circumstances (and they’re not foolproof). The White House took this theory way too far. When you use assurance testing with tons of people, particularly with people who aren’t focusing on any other precautions, it increases the already-present chances that a false negative will slip through. Despite this, in July, Trump explained that he doesn’t have to wear a mask because “everyone gets tested before they see me.”

For testing to provide real assurance to a person maintaining a high level of contact with others amid a pandemic, “everyone” really needs to be something like everyone. The sustained, top-down failure to do that kind of testing is the story of the catastrophic course of the virus in this country. There has been a lot of discussion about what mass testing could do to limit the spread of the coronavirus. (A few countries did use large-scale testing to control the spread of the disease.) Perhaps the clearest explanation of what widespread testing could accomplish comes from Atul Gawande’s New Yorker story about how America failed at testing and how it could still succeed. The story includes an example of a town in Italy that got out in front with mass testing much sooner than many other places did and dramatically lowered its number of cases over time because the people who needed to quarantine realized they had to, and their isolation slowed and reduced the spread.

What mass testing achieves, if done deliberately and correctly, is essentially close to what we hope a vaccine will do—over time, it limits the amount of virus in circulation to an eventual, negligible amount. It’s not perfect—as Christie Aschwanden has written, enforcing quarantine for people who have tested positive has its own obstacles. But it could be done.

The point is that if we want testing to work as a preventative measure, it has to be as part of a population-size approach to the virus, rather than an individual solution. But the White House always treated it as an individual solution: Donald Trump’s “everybody” was never actually everybody in America—it was just the everybody who comes into contact with him. While letting the virus run rampant in the rest of the country, the administration essentially tried to construct a bubble around Trump, without recognizing that making a bubble actually means restricting the number of contacts. The administration never understood the limitations of testing or the likelihood of false (or premature) negatives. It just kept testing the people who wanted an audience with the president, and put too much faith in the results.

Giving everyone access to testing—and the ability to quarantine if positive—would still be the best way to reduce the spread of the coronavirus in this country. Once again, our individual health is dependent on everyone’s else’s health. That is the lesson of this pandemic, and it is the lesson that the White House refused to learn—at our peril, and now its own.