Public health is at its best when it is pragmatic in the face of complex problems fraught with stigma and uncertainty, like moving in the direction of full vaccination in the face of many Americans’ entrenched or even defiant anti-vaccination sentiment.
It is neither insightful nor actionable to so singularly promote vaccination to decision makers who must confront the here and now of various attitudes toward it. Viewing Covid-19 testing as a complementary harm-reduction approach can address the well-being of unvaccinated people while slowly building trust and confidence in Covid vaccines.
But making that work requires a radical shift in the way testing is perceived. Many Americans view testing as a draconian intrusion to be feared if not outright avoided. The goal for public health should be to make testing look more like contraceptives: cheap, convenient, ubiquitous, and empowering. This is especially important in advance of a likely increase in test volume and test requirements during the fall and winter months, when Covid-19, influenza, and respiratory syncytial virus (RSV) infection will make diagnostic testing more important.
Changing the public perception of testing requires a dramatic change in rhetoric, and also requires that public health leaders and elected officials think differently about distribution and access as a prelude to changing social norms.
It is time to start thinking about the Covid-19 pandemic in eras.
In the first era, essentially year one, in the face of mounting deaths, limited treatment options, no vaccination, limited personal protective equipment, and profound uncertainty about the nature of the virus, public health leaders and government officials took the approach that made the most sense in that moment: they limited interaction. At one point, as much as 90% of the U.S. was in some form of lockdown. Testing was used primarily to tighten the seal on lockdowns. Containing people was the primary way to reduce contact to prevent infections, hospitalizations, and deaths, and public health was often the enforcer of this containment.
The second era, which began as we moved into year two, looks significantly different. The country has highly effective, safe vaccinations, more effective therapeutic tools, and plenty of appropriate masks that many people use in places when they are required. Ventilation systems have been checked and brought up to code. But there are also more transmissible and potentially more lethal variants, and more people, including children who cannot yet get vaccinated, coming out of lockdown.
In era two of the pandemic, even though the array of tools and the infusion of resources to make them available make it possible to think and act in new ways, the U.S. is still stuck in era-one thinking. In particular, testing continues to be treated and talked about mainly as a means of limiting access, which is a tremendous misstep for the pandemic at this stage.
The Biden administration recently announced an additional $1 billion investment in at-home rapid tests. That is in addition to the $2 billion investment announced in September to secure 280 million rapid-antigen tests as part of its plan to require employees of large companies to either get vaccinated or to be tested weekly. It also invoked the wartime Defense Production Act as part of a broader push to expand test manufacturing.
This is an important step in the right direction, but resources alone won’t be sufficient to pivot successfully to the next era of the pandemic. Set against the powerful backdrop of progress, testing should be reframed as a tool to allow people to more confidently gather in a world in which risks are still considerable.
Testing must shift from an ad hoc and symptomatic standard toward a ubiquitous, accessible screening paradigm. Covid-19 testing has not broken out of longstanding clinical paradigms in the way, say, pregnancy tests have, and our national practice has prioritized the sick and, in some cases, those with clear exposures. Testing needs to be widely available, convenient, and, depending on the setting, a cheap or free tool that healthy Americans who interact socially use regularly. Yet the country is mired in discussions of testing as an inconvenient, punitive measure, something that is used to exclude people from their work, from their friends, from their schools and universities.
We’ve seen both sides in our role supporting one of the largest university campus response operations in the country at The Ohio State University, where, during last year’s peak, more people were tested per week than in at least 10 states in the country. While many have been grateful for the free and convenient regular screening against a harmful infectious disease, we have also heard complaints similar to those heard by public health institutions around the country: Testing is a burden, a punishment for wanting and having fun, for living our lives.
It’s time to make asymptomatic testing so routine that individuals no longer fear the rare use of a test as a key to access a cherished event, but rather come to accept a new standard that enables large gatherings. It’s akin to enhanced airport security following 9/11. Applied more widely and more frequently in a context of rising levels of vaccination, testing provides the means to do more things collectively, not fewer. More concerts. More face-to-face higher education experiences. More restaurant experiences. More travel. Testing more people — vaccinated or not — more often in more places allows everyone to engage in social activities and events with less anxiety and greater safety.
But it needs to be clear that the reason for testing is so that we can all participate.
We call this a harm-reduction approach because it accepts that people will take risks. The emphasis is less about setting limits on individuals or continual nagging about risky behavior and more about changing the conditions required for individuals to gather and take those risks. With ubiquitous testing, and the right framing, the entire community can do more without the need to regularly mask or distance until it reaches the point where vaccination alone can sustain pre-pandemic levels of social gathering and interaction.
Combining a national investment in public health infrastructure with a radical shift in rhetoric and messaging about testing will allow the country to effectively respond to what is required in era two of the pandemic. In this second era, one with both ongoing risks and a better understanding of these risks, there is much to be learned from public health innovations such as pre-exposure prophylaxis (PrEP) to prevent transmission of HIV, distributing naloxone to first responders to reverse opioid overdoses, and needle exchange programs, all of which offer nonjudgmental approaches to individuals who cannot or will not change sexual or drug use behaviors.
Although harm reduction works, public health and community leaders have not been nearly bold enough in making services like naloxone or needle exchange truly widespread. For individuals who cannot or will not get vaccinated against Covid-19, public health and health care officials can meet them where they are at while managing known threats to community well-being if they learn the lesson from other efforts and make testing as widely available as possible so that it becomes a social norm, like brushing your teeth.
Wide distribution of and easy access to rapid tests can make them feel less like a punishment and more like wide distribution of free condoms, a measure that not only curbs sexually transmitted infections and unplanned pregnancy but also connotes freedom, choice, and empowerment.
Like all harm-reduction interventions, a saturation approach won’t be perfect. Nonetheless, more Covid-19 testing, in more places, on more days, creates freedom to interact and enjoy life.
Amy Lauren Fairchild is dean of the College of Public Health and a professor of health services management and policy at The Ohio State University. Samuel S. Malloy is a research specialist at the OSU Battelle Center for Science, Engineering, and Public Policy at Ohio State.