Testing is considered a major requirement on the path back to normal, and as the president has made clear, it's largely up to the states to find the way. Are states in the Mountain West up to the task? By multiple measures, Utah and New Mexico are leading the way, while other states are still lagging behind.
Utah and New Mexico are onto something. As data from the COVID Tracking Project show, they've consistently been ranked among the top dozen states in the country for COVID-19 testing per capita. And by late April, only about 5% of those tests came back positive, which is one potential measure for gauging adequate testing capacity.
Ashish Jha, director of the Harvard Global Health Institute, said those indicators together are strong signs the states are doing a good amount of testing.
"I think what Utah and New Mexico show us is that clearly this is doable," said Jha. "The people who think, 'Oh, testing is too hard, can't do it.' No, you can do it. And they've done it."
Colorado, on the other hand, has the opposite profile. It's consistently been near the bottom in per capita testing, and, as The Atlantic explains, its "test-positivity rate" of about 20% "implies that doctors are testing only people with a very high probability of having the infection. People with milder symptoms, to say nothing of those with none at all, are going undercounted."
"Colorado and others need to get their act together and move forward on this," said Jha. "Because they're not going to be able to keep their populations safe – especially as they begin to think about opening up – without much more aggressive testing."
How did Utah and New Mexico manage to pull it off when other Mountain West states couldn't? Some of it, Jha said, probably has to do with factors outside of a state's control, like the size of its population.
"But I don't think it's magic," he said. "I don't think it's just, 'You got lucky.'"
Turns out, there are at least two important assets that New Mexico and Utah brought to bear that appear to be playing a part.
Number one: In mid-March, New Mexico and Utah did something that other Mountain West states didn't. They tapped testing czars. Yes, czar means Russian emperor. But, as Slate has written, it's also come to refer to an interagency point person who coordinates between different entities to get something done. Testing czars are people whose entire job is to figure out how to ramp up testing, not just within public health laboratories, but across the board.
In Utah, that person is Nate Checketts. He said he avoids the title "czar." Technically, he's a deputy director with the health department, on "a special assignment to coordinate testing for the COVID-19 response."
In New Mexico, Dr. Steven Jenison fills that role. Technically, he's acting deputy secretary with the health department.
"I was brought out of retirement in order to address, specifically, issues around the expansion of testing capabilities in the state of New Mexico," he said.
Jenison is a retired physician and infectious disease specialist. He spent 15 years with the health department's infectious disease bureau. He has a long history of working with viruses, including working on a hantavirus outbreak a few decades ago. Now, all he thinks about – "16 hours a day, seven days a week" – is expanding New Mexico's coronavirus testing.
Jenison started by getting a lay of the testing landscape. He learned that two big healthcare companies seemed to have a good handle on testing in urban areas, so Jenison and his colleagues focused energy on rural areas – helping county health departments get testing sites up and running. By mid-April, he said, "on any given day there are between 50 and 60 testing sites that are routinely doing testing."
In Utah, Nate Checketts was focusing on identifying the bottlenecks holding labs back from testing more.
"When I first came into this role, the issue that we were facing was that the labs had the machines to perform the testing and the different phases of the testing," he said. At that point they had plenty of swabs, too. The limiting factor was reagents – the chemicals required to pull genetic material out of a patient's sample.
"So we made a massive effort – a statewide search – to try to find reagents," said Checketts. "And we found them everywhere."
For example, he said, one manufacturer found a box of 750 test kits lying around, and donated them to the state. Checketts said that helped buy some time to figure backup options for the future.
More recently, swabs became the limiting factor. Checketts said the state was able to buy an emergency shipment of 100,000 swabs to keep testing from slowing down. He's now talking to local manufacturers about making swabs in-state, so they don't have to rely on unpredictable and far-flung shipments.
Checketts also set up a three-times-a-week conference call with all the laboratories in the state.
"Every Monday, Wednesday, and Friday in the evening we get together for an hour and run through these issues," he said. He said the labs have been trading tips, like leads on where to get supplies, or advice on how to get a certain test to work – even, at times, sharing materials.
That brings us to the second thing that stands out about Utah and New Mexico: their laboratories.
Most of the Mountain West has relied largely on three entities for COVID-19 testing: their public health labs, plus two national companies, LabCorp and Quest. By mid-April in Colorado and Nevada, those two companies combined had conducted about half of each state's COVID-19 tests, with public health laboratories and a collection of smaller labs shouldering the rest.
Over the same time period, Utah and New Mexico showed a different breakdown. In those states, LabCorp and Quest accounted for a combined 7% and 16%, respectively, of COVID-19 tests. Instead, the testing heavyweights in those states were two lesser known labs, both locally based. (Detailed data wasn't available for Montana, Idaho and Wyoming).
In Utah, it's a lab called ARUP Laboratories in Salt Lake City. In New Mexico, it's a lab called TriCore Reference Laboratories based in Albuquerque.
Both are big reference laboratories, with long-held ties to both local healthcare systems and the state university (the University of Utah owns ARUP). These are laboratories that, even before the pandemic, were working 24/7 analyzing samples from patients – often for viruses. And both of them already had some of the high-capacity machines needed to rapidly test a bunch of samples at one time. When the COVID-19 pandemic hit, they quickly took on the lion's share of testing in their home states.
"We are a non-profit, academic, national reference laboratory," said Dr. Julio Delgado, chief medical officer of ARUP, who confirmed that the company shared supplies with other labs in order to keep COVID-19 testing moving in the state. "We have a little bit of liberty to do things that we think are the best for a situation like this. We don't have that shareholder – you know, people on top of you that sometimes prevent you from doing the right thing."
Delgado said outbreaks like Zika virus had already prepared ARUP to some extent for viral epidemics.
"So we had all the instrumentation," he said, "And then we were able to quickly deploy them for this type of testing."
Initially, ARUP was accepting samples from patients across the country, as they usually do, but Delgado says they quickly got swamped. So they had to make a difficult decision: to stop accepting samples from so many places.
"That was probably the five most difficult days of my life as a professional," said Delgado.
In the end, they decided to focus primarily on testing in Utah (though, he adds, they continued to do some testing for Wyoming, Idaho and Colorado).
In New Mexico, TriCore Reference Laboratories has played a similar role.
Dr. Douglas Clark, chief medical officer, said that, like ARUP, they already had some of the diagnostic testing equipment needed to run COVID-19 tests quickly.
"We didn't have to purchase the instrumentation, bring it in, get it validated. It was already here," he said.
Clark said it also helped that TriCore has a big footprint across the state, working with a bunch of healthcare sites including 15 hospitals.
"That really allowed us to have access to [a] large number of patients as soon as the pandemic began here in New Mexico," he said.
Dr. Richard Scanlan, chair of the College of American Pathologists Council on Accreditation, the organization that vets diagnostic laboratories across the country, said there are a lot of possible explanations for Utah and New Mexico's relative testing successes. But, he said, "I would say those states were extremely fortunate to have large, efficient reference labs that could deal with testing demands generated locally and get some preference possibly for local samples."
Quest and LabCorp are large and efficient, but Scanlan said, "The fact that these two semi-rural states did so well in their testing per capita – it raises the question of whether it's better to have a really good medium-sized grocery store than to get your groceries from Amazon Prime."
There are other things about our states that could create significant differences, though their relevance to the issue of testing is uncertain. For example, according to a report from the organization Trust For America's Health, a non-partisan non-profit promoting public health, New Mexico trounces other states in the amount of money per capita the state puts toward public health programs. A report from the Association of State and Territorial Health Officials (ASTHO) shows Utah and New Mexico are the only states in the region with freestanding health departments that aren't housed under a larger health and human services organization. According to the same report, Colorado is the only state in the region where the top state health official reports directly to the governor. And New Mexico stands out as the region's only state with a centralized health department, which Steven Jenison said helped streamline its ability to get testing sites up and running across the state.
"Those kinds of situations often are more efficient," said Dr. Marcus Plescia, the chief medical officer for ASTHO, compared to so-called "home rule" where health departments at the local level are autonomous. "I think there's pros and cons to each."
In addition, recent developments could further boost New Mexico and Utah's testing numbers. For example, last week Denver-based National Jewish Health, a national reference laboratory focused on immune and respiratory conditions, began processing 400 to 500 COVID-19 tests a day for New Mexico patients. And Utah's tech sector has blasted onto its testing scene.
Silicon Slopes, a non-profit advocacy organization for Utah's tech and startup community, partnered with the state for a campaign called TestUtah. As Mark Newman, CEO and founder of Nomi Health and chairman of Silicon Slopes' COVID-19 health response committee, explained, they "automated the entire workflow," applying the methods used by companies to screen and schedule large numbers of job applicants to screening and scheduling large numbers of COVID-19 tests at multiple sites. TestUtah is responsible for a reported 12,000 COVID-19 tests since its launch April 2, and is now expanding to other states. They use test kits from a Salt Lake City company.
There's another element that could also help explain the states' relative testing successes thus far. As Marcus Plescia of the Association of State and Territorial Health Officials put it, "Some of it may just be some good decisions that got made."
Utah's Nate Checketts said leadership in his state prioritized testing early on.
"It's a core part of every state's strategy, but we've really leaned heavily into that as trying to find a way forward through this crisis," said Checketts.
Steven Jenison echoed that sentiment. He said in New Mexico, Gov. Michelle Lujan Grisham took testing seriously from the beginning.
"She was the secretary of health when I worked for the department of health for many years," he said. "I believed that this governor was doing the right things and doing them early."
Enough so that it felt worth it to leave what he calls a "fairly blissful retirement" to enter the COVID fray.
This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.
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