TESTING is the starting point of most scientific conversations about Covid-19. Public health systems in Pakistan have been rightly focused on addressing the supply side — the availability and deployment of testing capacity. Nationally, we are able to do 10,000 tests daily, and this number is not yet rising rapidly enough to support us through any post-lockdown strategy. Even as we increase testing capacity, a critical issue remains neglected: who actually gets tested? This question requires urgent answers and redress if we are to have a realistic chance of containing the spread of the virus post-lockdown, and ensuring that there is sufficient critical care available for those who will require it.

On paper, “who actually gets tested” depends on a combination of two processes: who asks for a test, and of those who ask, who qualifies to be tested. The easier one first: who qualifies for a test? Tests are rationed everywhere in the world. Some people such as travellers from outside the country are subjected to mandatory testing. For the rest, there are guidelines that are issued nationally for identifying and testing suspected cases. A person may qualify as a ‘suspected case’ depending on her or his symptoms, travel and contact history, and occupation (e.g. health workers). According to National Institute of Health data, there were over 25,000 more tests conducted nationally than there were ‘suspected cases’. These were paid for privately by individuals, and may not have conformed to guidelines, and their number has declined in the last two weeks.

Now the more difficult question: who asks for a test, and why? Testing strategy depends on individuals coming forward and identifying themselves as possible suspected cases. How sound is the assumption that suspected cases will come forward?

Viability of any post-lockdown containment strategy depends on catching symptomatic cases early, and then tracing others with contact history

This question is less critical in functioning public health systems such as the National Health Service in the UK where there are established norms in the population of referring to public health services in the event of any health-related contingency. What about a situation in countries like Pakistan where individuals are not linked with public health services?

The private sector is the predominant supplier of a wide range of services, including hospital care for a majority of the population, and there is a widespread culture of self-medication. Much of our urban population gets into contact with public health services only as a last resort.

In this context, three features of Covid-19 present a unique challenge. First, the disease can be spread by people who display no symptoms. Second, a vast majority of those infected will display mild symptoms and will recover without medical intervention. Third, there is no current treatment available for patients except for life-saving interventions for those with severe symptoms.

There are still ‘private benefits’ of a suspected case presenting herself or himself for a test. Since many of the symptoms of Covid-19 are similar to those of less serious ailments, there is peace of mind to be gained by testing negative, and this is one factor behind the large number of paid-for tests by people who did not, otherwise, qualify as ‘suspected cases’. But for the most part and for most people, the ‘benefits’ of testing positive accrue to others. A person who tests positive may take extra care to protect her or his loved ones from getting infected.

What about factors which might inhibit people from coming forward to be tested? For those with mild symptoms rigorous self-isolation might feel like a cost. In the absence of paid sick leave another cost might be loss of earnings. There may be stigma attached to being identified as a potential carrier. Relatedly, individuals may be apprehensive of intrusion and loss of privacy if a positive test result triggers the enforcement of quarantine and contact tracing. The demand for privately-paid tests might have dried up as more people realised that testing positive placed them on a national database. While families might be vigilant within their own constraints with respect to self-isolation and distancing, they may not welcome public intrusion into their private domain. There is anecdotal evidence of individuals trying to conceal their positive or suspected case status to avoid social stigma or the loss of livelihood. There is also anecdotal evidence of individuals making their first contact with the public health system with advance symptoms — some too late to be saved.

The viability of any post-lockdown containment strategy depends on catching symptomatic cases early, and then tracing others with a contact history. Once testing capacity increases, and even before then, inhibition on the ‘demand’ side of testing — due to weak private benefits, and high perceived costs — will emerge as a critical bottleneck. In the short term, public messaging will need to be strengthened to make the benefits of testing more salient and proactively dispel fears such as social stigma and loss of privacy. ‘Smart’ measures which appear to be punitive — such as mandatory quarantining, publicly identifying ‘hotspots’ or community-level lockdowns — will further inhibit the demand for testing. In the longer term the case for a stronger and more durable relationship between individuals and the public health system is inarguable. Until then, we may have to accept the fact that we may identify positive cases too late to save them, and too late to effectively contain the spread of the disease.

Published in Dawn, May 27th, 2020