As we all grapple with what it means to live in society battling a global pandemic that is so fundamentally altering the way we interact with one another, we are faced with several questions we haven’t faced before in our lifetime: how are we going to move forward from this? What does a post-COVID-19 world look like? When will we be able to go back to “normal”?

While all of these questions are important, there is an underlying issue lingering in the background: COVID-19 testing. Testing is a critical component of responding to a public health emergency, and without it, tracing possible COVID-19 exposures would be nearly impossible, and for our testing strategy to effectively combat the spread of COVID-19, we have to address the issues surrounding misinformation, confusion, privacy, staffing, and trust surrounding the tests, so citizens feel comfortable getting tested.

With news from the White House falsely attributing the United States’ high COVID-19 numbers to the amount of testing, states are starting to open and remove social distancing regulations leading an increase in the percentage of positive cases in many states — a statistic used to assess increasing numbers while controlling for increased testing. This among other bouts of misinformation coming from the president surrounding the severity of COVID-19 which has since been proven to be false.

To add to the confusion surrounding testing, there are many different tests with varying sensitivity (the statistic that measures the ability of a test to catch all positive cases) and specificity (the statistic that measures the ability of a test to differentiate between similar conditions). Additionally, there are different tests for different purposes — some measure the presence of a virus indicating active infection while others measure antibodies to the virus indicating prior infection and possible immunity to future infection.

Additionally, many citizens are concerned with the privacy of their COVID-19 test results, especially as concerns about sharing data with the police, data breaches, and distrust in contact tracing.

Legally, personal health information and personally identifiable information are protected by HIPAA, but in a public health crisis or pandemic, that information can be “disclose[d]… [to] law enforcement, paramedics, other first responders, and public health authorities” (HHS). This divergence from the typical HIPAA regulations is done in an effort made to protect the first responders and provide information for contact tracing and is common to many areas of law during a public health crisis.

In general, rules and regulations that govern clinical ethics and protect personal liberties are less useful in a public health crisis.

For these reasons, public health interventions are governed by a different ethical code with a stronger emphasis on justice and care for communities rather than autonomy and personal liberty.

Central to the ethical code of public health ethics is building and maintaining trust as well as a strong basis in science. So no matter how strong our public health institutions are, we need to have a stronger emphasis on building and maintaining trust. Because without that, we will not be able to implement anything meaningful to combat this pandemic or any future public health crisis.

Another consideration is the testing personnel required to perform the tests. Though patients may never see the technologists performing their lab tests, they play a central role in health care delivery. Still, hospital systems and insurance reimbursements widely underfund the support of these departments despite providing 60 to 80 percent of the information needed to make a diagnosis.

Additionally, many laboratory scientist positions are being left vacant because of the lag in training — a problem that could also be partially addressed by increased funding and earlier exposure. All of this comes in addition to recent shortages in testing capacity due to recent rises in cases.

Since testing and tracing is a central tenet to curtailing the spread of COVID-19, we have to ask ourselves, considering the above ethical principles guiding public health interventions, what is the best way to offer testing in a way that stems the spread of COVID-19 while protecting patient information and fostering public trust?

Should we follow the precedent set forth by Germany, where massive testing and teams of contact tracers were implemented? Or should we adopt the strategy of South Korea where free, convenient testing locations were made available paired with cell-phone data tracing? Or do we want to maintain our course of action by testing symptomatic people and contact tracing when available? If we decide to move forward with more testing and more contact tracing, we have to consider the challenge of test turnaround time and delays in contact tracing: challenges that have led to the continued spread of the virus while awaiting results.

The question of who to test, when to test, and how to test is still only part of the puzzle and must be paired with evidence-based policies at the federal, state, and local levels that are aimed at quelling the spread of COVID-19, preventing our hospital system from getting overwhelmed, and avoiding avoidable deaths. Between facial coverings, social distancing, contact tracing, testing, and research, all aspects of the public health response and public involvement need to work together to combat this crisis.

In addition to classic public health measures, more coherence between community leaders and the state/federal government allows local issues to be assessed by public health officials and addressed by local community leaders to bolster trust. Additionally, testing should be made more readily available and take place in local community institutions to help break barriers to getting tested. I also support providing a statement that can be given to citizens, written in plain language, addressing privacy concerns, what to expect when you get your results back, and what the results mean. Finally, we need to shift more funding into laboratory medicine, so we are not left with the severe staffing shortfalls currently being experienced. Without these measures, we will be faced with growing distrust, rapid spread of the virus, and continued questions over what to believe.

Cullen M. Lilley is a medical student.

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