Recently, I took care of a young man. He was 31. All of the classic symptoms. First, he lost his sense of taste and smell. Then diarrhea and nausea. A few days later, he started to cough. After a few days of having trouble breathing, he showed up at the urban emergency room where I work. He had actually been tested two weeks before for COVID-19, but the results from a community testing site never came back. Even without the rapid test that I sent to the lab, I knew that this very sick young Black man lying hunched over in the hospital bed had a severe case of COVID-19.
As the young man’s experience illustrates, it is not just a challenge to get a test but to also understand what it means, and what to do with the results once you get them, or what to do while you wait for the results. The recent controversy over CDC guidelines for asymptomatic people who were exposed to infection doesn’t help. Friends and family members corroborate what I have heard from providers testing in the community. There is an information gap -- whether you are notified of your results 2 days or 8 days later. Days to weeks after their initial symptoms and test, there is often a lack of real-time contextual information alongside the result of “positive” or “negative.”
Credit: contributed
Credit: contributed
Among policymakers and news organizations, we’ve seen increased attention to disparities in testing access. Overlaying a demographic map of the Atlanta area with a map of COVID-19 testing sites, it is easy to see. Testing sites are more plentiful in majority white neighborhoods and they are scarcer in communities of color. Nationwide, an analysis by the news organization FiveThirtyEight found fewer testing sites in communities with a majority of racial minorities and these testing sites more likely to have longer wait times and understaffed testing.
The Surgo Foundation found that nearly two-thirds of rural counties in the United States do not have a COVID-19 testing site. The Foundation described them as “testing deserts.” And when ranked according to the spread of infections and mortality rates, most of the top vulnerable counties have a higher proportion of Black residents compared to national average. Three of the top 10 counties were here in Georgia (Terrell, Calhoun and Worth counties).
It is this general lack of access -- to testing, information, care — that is driving the disproportionate burden of this pandemic in vulnerable communities. My colleagues at the Emory Clinical Cardiovascular Research Institute have been mapping COVID-19 social vulnerability at the county level, and there is a clear correlation with case fatality rates. “Testing deserts” are reflective of the inbred inequalities in our communities. They look strikingly similar whether we are looking at COVID-19, maternal mortality, or food insecurity.
Looking ahead, we welcome more funding for testing infrastructure, whether at the federal level or coming from private nonprofit groups. However, our experience in vulnerable communities reminds us that testing deserts are not just the absence of testing sites, but also absence of reliable, real-time information. Statistical modeling predicts that if testing results came back the same day and were accompanied by rigorous contact tracing, 80 percent of cases could be avoided. Test results coming back a week later, even if accompanied by contact tracing, would only prevent 5 percent of onward transmission. In communities where testing is inaccessible, fewer members are being tested and this is further compounded by the likelihood of delayed results.
It is essential that testing programs be coordinated -- not at a grassroots or single hospital level but at the regional and national level. Still, supply chain limitations on large-scale testing require us to design programs that are actionable for high-risk communities. This means targeted efforts to deliver critical information and testing alongside wraparound care. Mobile-first is an important bridge for people who do not have broadband access, and in our work at Health DesignED, we have been working with our partners at Access Mobile and Vital to design technology services that span the digital divide. Building on the c19check.com symptom checker app, we have designed a mobile engagement campaign to reach people on the phone through trusted messengers in a behaviorally sensitive way.
We are identifying ways to partner with community anchor groups in metro Atlanta to connect tailored messaging with testing in real time. This is a replicable model that is agile enough to meet evolving knowledge and shifts in resources, whether we are talking about testing or future vaccines.
Monique Smith, M.D., is part of the Department of Emergency Medicine at Emory University School of Medicine and an emergency physician at Grady Memorial Hospital in Atlanta.
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