By revealing whether COVID antigens are present, rapid tests help people avoid situations in which they may infect others. Anyone worried about a possible exposure to the virus undoubtedly wants to take precautions to protect loved ones and others from danger. They especially want to protect those most vulnerable to the virus, such as the elderly.
Despite the potential for rapid tests to empower these people, at-home tests are not flying off the shelves—quite the opposite. The dream of people testing themselves with rapid tests en masse has not come to fruition, despite considerable hope and advocacy. One manufacturer even destroyed its inventory due to a lack of interest from the public.
Lackluster interest in rapid tests reflects many factors, including seasonal variation in COVID prevalence. Some of those factors are firmly within our control.
A key obstacle to rapid tests is that COVID testing presents people with an incentive problem. Testing offers a definite benefit—information—but also imposes a significant cost—mandatory isolation following a positive test. Contact tracing of family, friends and others, as well as possible mandatory isolation, further add to this disincentive.
Mandatory isolation disincentivizes testing for a simple reason: the rules are very rigid, while the facts about COVID—such as what situations present the greatest risk for infection and who are the most vulnerable—are highly nuanced.
Infection with the coronavirus poses a mortality risk about 1000 times higher for the elderly than for the young. When infected, young people have a powerful incentive to avoid visiting grandparents but a much smaller incentive to avoid meeting friends. Because mandatory isolation rules do not account for this nuance, they impose a disincentive for getting tested in the first place.
Another important fact: the virus is much more likely to spread indoors than outdoors. Meeting others outside is relatively safe. Mandatory isolation rules ignore this nuance, again presenting a disincentive to be tested.
Mandatory isolation rules also ignore the nuances of our daily lives. Meeting a healthy grandparent for a weekly game of cards is quite different from meeting her on her deathbed. No government rule can truly navigate this difference, which is so personal and so human.
Rapid tests have failed to gain traction among the general public because the primary motive for testing—immediate information to distinguish safe and unsafe activities—is at odds with the disincentives created by the “test, trace and isolate” paradigm that public health officials have monomaniacally pursued since March 2020.
The first at-home rapid tests required reporting through a phone app for interpretation, a form of mandatory reporting. Some tests are now available that work like a pregnancy test, with a fast result shown privately. For the latter, even if the test is negative and you have no symptoms, the CDC still recommends quarantine if you may have been near someone with COVID. If the test is positive, then the CDC recommends isolation.
Of course, anyone can ignore the CDC’s recommendations; the test result is private, after all. But in practice, such public health recommendations come with a moral force that many find hard to ignore without guilt, which is itself a cost. And since the tests themselves are not 100 percent accurate—no test ever is—the hassle of a quarantine mandate may end up serving no public health purpose.
Rigidity is unavoidable for any isolation rules imposed by government fiat. Such mandates can never anticipate every contingency. And public health regulations have good reason to be concise: they must be easily communicable and understandable by a broad audience.
The only way out of this bind is to eliminate mandatory isolation and contact tracing.
There is hardly any downside to eliminating the test and trace paradigm, which has not fulfilled its promise. Though touted as a way to stop viral spread or even eradicate the disease, it has accomplished neither. Over and over again, testing and tracing efforts have been overwhelmed whenever a seasonal COVID wave hits.
Ending contact tracing—except in high-risk settings such as elderly care homes—and eliminating mandatory isolation for asymptomatic contacts are important first steps. They will free up scarce health care resources for more productive uses, keep kids in school and nudge upward people’s incentive to buy and use rapid tests to protect the vulnerable.
But public health authorities can go even further. They should eliminate all mandatory isolation requirements for those who test positive for COVID, keeping isolation recommendations only for those with symptomatic cases. Doing so will remove the considerable disincentives still inherent in COVID testing and finally give rapid tests their chance to empower people to make good decisions that benefit the health of us all.
Jay Bhattacharya is a Professor of Medicine at Stanford University. Mikko Packalen is an Associate Professor of Economics at the University of Waterloo.
The views expressed in this article are the writers’ own.
