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Wednesday, May 6, 2020

By Anna Maria Barry-Jester and Angela Hart and Rachel Bluth

KHN.org

 

SACRAMENTO—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.