ProPublica's health reporter Caroline Chen explains what the conversation around asymptomatic coronavirus carriers is missing, and what we need to understand if we're going to beat this nefarious virus together.

The article was first published on Thursday, April 2, 2020 in ProPublica.

By Caroline Chen

In the early days of the coronavirus outbreak in the U.S., around the last week of February, I joked to a colleague that maybe now, finally, people would learn how to wash their hands properly. My remark revealed a naive assumption I had at the time, which was that all we needed to do to keep the novel coronavirus contained was follow a few simple guidelines: stay home when symptomatic and maintain good personal hygiene. The problem, I thought, was that nobody was following the rules.

In the past few weeks, however, more and more reports have emerged to challenge my neat assumptions. Seven out of 14 NBA players, coaches and staff who tested positive didn't have symptoms when they were diagnosed, The Wall Street Journal reported. The U.S. Centers for Disease Control and Prevention issued a case study on a nursing facility in King County, Washington, where 23 residents tested positive for COVID-19, and it found that 13 reported no symptoms initially. Sixty singers went to rehearsal and followed all the rules, according to the Los Angeles Times — nobody hugged, shook hands or appeared ill — yet three weeks later, 45 were diagnosed with COVID-19 or had symptoms of the disease, and two have died.

With articles about "silent spreaders" and "stealth transmission" flying across the internet, friends were starting to text me: Was it still OK to go for a walk with a friend, even 6 feet apart? Or should all interaction be avoided? Should we start wearing masks to the grocery store? At the same time, my colleagues were scrutinizing guidelines at various workplaces and agencies we cover: The New York City Fire Department told workers on March 19 they were to come to work, so long as they had no symptoms, even if they had had "close contact with someone who is a known positive COVID-19 patient," according to a document obtained by ProPublica. Was that policy wise?

I decided to dive into the available data. What I discovered is that not only can people be infected and experience no symptoms or very mild symptoms for the first few days, but this coincides with when the so-called viral load — the amount of virus being emitted from an infected person's cells — may be the highest. That makes the virus a truly formidable opponent in our densely packed, globally connected world. We're going to have to be smarter than this virus to stay on top of it.

What does asymptomatic really mean?

Let's start with the basics. Dr. Maria Van Kerkhove, head of the emerging diseases and zoonoses unit at the World Health Organization, told me that the WHO so far has found few truly asymptomatic cases, in which a patient tests positive and has zero symptoms for the entire course of the disease. However, there are many cases where people are "pre-symptomatic," where they have no symptoms at the time when they test positive but go on to develop symptoms later.

"Most of the people who were thought to be asymptomatic aren't truly asymptomatic," said Van Kerkhove. "When we went back and interviewed them, most of them said, actually I didn't feel well but I didn't think it was an important thing to mention. I had a low-grade temperature, or aches, but I didn't think that counted."

The WHO sent a team to China and visited community centers, clinics and hospitals, and transportation hubs. Through their data collection, the team found that about 75% of people who were initially classified as "asymptomatic" went on to develop symptoms, she said. This matches up with the CDC's findings at the nursing facility in Washington. Of the 13 positive patients who initially reported no symptoms during testing,10 later developed symptoms.

But ultimately, the only way to really find out how many asymptomatic COVID-19 carriers are out there would be to conduct blood tests across large swaths of the population to look for antibodies, which are a type of protein that provide evidence that a person's immune system did battle with the coronavirus. Tests that can look for these antibodies are now being developed in several countries.

For the purposes of containing the outbreak right now, however, Jeffrey Shaman, a professor of environmental health sciences at Columbia University's Mailman School of Public Health, says the focus on asymptomatics is a bit of a red herring.

"In some sense, symptomatic versus asymptomatic isn't really the appropriate dividing line" for us to be focusing on, he said. "The appropriate dividing line is documented versus undocumented infection."

What Shaman means by "documented" is people who are identified as being infected, either because they were sick enough to go seek care or were tested through contact tracing, which is when public health officials track down all the contacts of someone who tested positive. The "undocumented" could be people who have symptoms but didn't get tested, because of lack of access to testing, dislike of doctors or sheer stoicism — or more concerningly, people who had no symptoms or such mild symptoms that they decided to just carry on with their daily lives.

"Maybe they pop some ibuprofen, but still go to work, still get on public transportation, still do all the things we normally do, and the consequence of that is those people with mild infections — as well as if they're truly asymptomatic — are taking the virus out into the community, and they're spreading it far and wide," Shaman said.

Shaman and colleagues published a study in the journal Science on March 16 in which, using a statistical model, they estimated that 86% of all infections in China were "undocumented" prior to Jan. 23, when Chinese authorities cut off Wuhan, canceling all planes and trains leaving the city. This would help explain the rapid spread of the virus across the country, they said, concluding that their findings "indicate containment of this virus will be particularly challenging."

The disease IS spread by liquid "droplets." But the human body has lots of ways of creating these minuscule, virus-laden flecks.

If there are thousands of asymptomatic or pre-symptomatic people out in public, how are they transmitting the disease, if they're not coughing or sneezing? After all, as I'm sure many of us have heard, this disease spreads primarily via droplets.

The WHO's Van Kerkhove said research so far shows that liquid droplets are necessary to transmit the virus, and they need to go from the infected person's mouth or nose into someone else's eyes, nose or mouth. (People can also get infected if they touch a contaminated surface where a droplet has fallen onto and then touch their eyes, nose or mouth.)

But sneezing and coughing aren't the only ways droplets get transmitted.

"People clear their throat," Van Kerkhove pointed out. "Some people spit when they talk." I winced.

Angela Rasmussen, a virologist at Columbia's Mailman School, provided more vivid descriptions for my mental tableau. "Droplets are not necessarily huge, like globs. We release respiratory droplets when we speak."

"When you go outside and it's really cold out and you see your breath fog — that's respiratory droplets," she said.

This doesn't mean that the coronavirus is being transmitted as an "aerosol," which is the term that many researchers use when virus particles remain suspended in the air for long periods of time. That applies to the measles virus, for example, which is why that microbe is so incredibly contagious.

However, it does mean that if you're standing right next to someone who is infected and they're talking to you, or, say, if you're in a room full of singers who are projecting their voices in an enclosed space, there are going to be droplets in the air, and yes, you could inhale them.

What's still fuzzy is exactly how far one needs to stand in order to be ideally protected from coronavirus droplets. The WHO says 1 meter, or 3.2 feet. The CDC says 6 feet. Lydia Bourouiba, a fluid dynamics expert at the Massachusetts Institute of Technology, published a paper last week that said that "peak exhalation speeds" can create "a cloud that can span approximately 23 to 27 feet." Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, later called the study "terribly misleading."

While the exact measurements are being debated, the experts I spoke to said that if you have to leave home, staying outdoors is the safest bet, since open air can help to "dilute" any potential microbes that reach you. While, of course, this isn't free of risk, one has to balance that risk against, for example, the mental and physical health benefits of going out for a run. So keep going out to exercise, the experts said. Maintain a 6 foot distance, at least.

You're likely most infectious right after you contract the virus, possibly before you know you're sick.

So we have a virus that can transmit from one person to another, standing a few feet apart, in the course of conversation, perhaps helped along by a few errant throat clearings, while the infected person either didn't have any symptoms yet or had a few minor body aches they didn't think much of.

That's already a recipe for a bad outbreak, but this coronavirus has another aspect that's helping to amp up its contagion factor. Studies are now finding that people are shedding more virus during early stages of the disease rather than the later stages.

The term "shedding" may bring to mind my cats, whose fluff seems to evade even my most ardent of vacuuming attempts, but it doesn't actually mean that virus particles are being emitted off patients' skin in an infectious cloud. It's a term used by researchers measuring the amount of viral RNA from someone who is infected, from a sample gathered via a method like a throat swab.

When nurses at one Washington State hospital complained about having to use expired respirators, they allege that staff were ordered to remove stickers showing the equipment was years out of date.

A study of 94 patients in Guangzhou, China, found "the highest viral load in throat swabs at the time of symptom onset" and concluded that meant that patients would be most infectious right before or at the time when symptoms started appearing. That study was published online as a pre-print and has not yet been peer-reviewed, but lead author Dr. Gabriel Leung, dean of medicine at the University of Hong Kong, said it has been accepted for publication in the journal Nature Medicine. Another study, also conducted by researchers in Hong Kong and published in the journal Lancet last week, found that viral load, this time in a saliva sample, was "highest during the first week after symptom onset and subsequently declined with time."

The authors of the Lancet paper noted that this profile contrasted with COVID-19's coronavirus cousins SARS, where the peak viral load was around 10 days, and MERS, at the second week after onset of symptoms. COVID-19's "viral load profile" actually appears to be more similar to the flu, the authors wrote, which also "peaks at around the time of symptom onset." Viral load is thought to correlate with a patient's ability to infect others, and when the peak comes later on during the course of disease, it's more likely that a patient will have already sought care, been tested and either started treatment or gotten instruction to stay isolated.

The high viral load early on in the course of disease for COVID-19 patients "suggests that [the virus] can be transmitted easily, even when symptoms are relatively mild," wrote the authors of the Lancet paper. This finding "could account for the fast-spreading nature of this epidemic."

All of this makes it extra hard to set workplace standards.

Against this wily virus, it's difficult to set comprehensive guidelines. "What we recommend is if you're feeling unwell, stay home," said the WHO's Van Kerkhove. That sounds simple, but after our conversation, I was doubtful as to how to carry this out. What counts as "unwell"? If I wake up with a scratchy throat, how can I tell if that's seasonal allergies or a potential early COVID-19 symptom? When's a headache just a headache?

I'm fortunate that I've been able to work from home for the past month and rarely need to leave my apartment. But many aren't that lucky. My colleague Michael Grabell recently wrote about workers in the meatpacking industry who often don't have paid sick days and work shoulder-to-shoulder. Even if on paper, their employers say they "don't want team members who feel sick to come to work," it's unclear what counts as "sick" enough that they won't get in trouble.

I asked the CDC, given what its own studies are finding on asymptomatic transmission, how workplaces are supposed to set policies, and the agency directed me to this page, which says: "Employees who have symptoms (i.e. fever, cough, or shortness of breath) should notify their supervisor and stay home."

Like the WHO instructions, that really doesn't seem to address the questions posed by a virus that can be spread by people before they experience symptoms. But it's also understandable why agencies are setting guidelines around black-and-white things like fevers (which are objectively measurable) and coughs (which is also a binary call). It's pretty much impossible for the CDC to weigh in all the possible symptoms that this coronavirus might cause, especially the more subjective ones like mild headaches or fatigue, even if they could turn out to be early COVID-19 symptoms for some.

Dr. Raphael Viscidi, a professor of pediatrics at Johns Hopkins School of Medicine who worked on a vaccine for the SARS coronavirus, notes that there are different standards being asked of the general population and of essential workers, for good reason.

"On a population basis, the message has to be strong, it has to be consistent, and it has to be repeated: We have to exercise maximum social distancing," he said. "But then you start saying, well, what about the people that have to go to work?"

Hospitals that are short-staffed don't have the luxury of having conservative policies and telling staff to stay home and quarantine themselves before they exhibit symptoms, even if they've been exposed to someone who has a confirmed infection.

"The problem is we need the health care responders, because we have to care for the critically ill, so there's probably going to need to be an exception," said Columbia's Shaman. "And they're going to have to rely on their PPE, the personal protective equipment, to prevent them from spreading it to other people."

Viscidi acknowledged: "You are giving one message to the people you're asking to work and another message to the general population. For sure, some people are forced to take slightly greater risks."

We've got to fight this virus with all we've got. Here's how we do that.

Since symptoms-based policies alone cannot be perfect, we need to turn to other strategies to catch the people who slip through the gaps presented by a broad "If you're feeling unwell, stay home"-type recommendation.

In recent days, there's been a new enthusiasm for masks, with many calling for widespread use among the general public. The idea there is that masks could help prevent droplets from traveling far, particularly from an asymptomatic person who doesn't yet realize they're infected.

Leung, from the University of Hong Kong, is a fan of this idea. "Wear a mask, preferably universally in public spaces," he said, when I asked him how to solve the problem of asymptomatic transmission. But he also pointed out that there's a practical hurdle to this plan — "Of course this is not possible for some places where there are mask shortages even for hospital workers," which would be most of the United States.

After months of saying that healthy individuals should not wear masks, administration officials are now considering guidance for much broader, communitywide use of masks, Fauci told CNN on Tuesday.

In an absence of an abundant supply of masks — which, by the way, also need to be worn properly to provide protection — both the WHO and CDC stressed how important social distancing was. "COVID-19 spreads between people who are in close contact with one another," the CDC said in a statement. "That's why the CDC recommends staying at least 6 feet away from other people, so someone doesn't spread the disease if they are sick or are exposed through contact with someone who is sick."

Not only can social distancing protect you as an individual, but the better the general public is at adhering to these guidelines and staying at home, the less virus will be circulating in the public to potentially infect paramedics, grocery store workers and public works employees and other essential staff.

For workers who absolutely have to turn up in person, Columbia's Rasmussen explained to me that dose also matters. We understand this instinctively. If someone infected sneezes straight at you from a foot away, splattering your entire face with wet gunk, you're going to feel more nervous about your likelihood of getting sick than if a single virus landed in your mouth.

"It's not always as simple as you come into contact with a single infectious particle and you're going to be infected," Rasmussen said. "You usually have to have a certain number of those particles in order for them to evade the immune system, get past the mucus barrier that's in your nose and throat, come into contact with a cell that has the virus receptor on it, and then get into the cell and start replicating."

So increasing the chance that the virus will be "diluted" is important. That means workplaces like meatpacking factories and delivery warehouses should do whatever they can to space out their workers, and not have meetings en masse in indoor spaces, where droplets are likely to persist and don't have a chance to be carried away by wind. And of course, companies should have generous sick leave policies, so workers can err on the side of caution if they do feel unwell.

And let us not forget about testing. Testing is critical, because it can let people know if they're sick before symptoms emerge and prompt them to self isolate. At a big picture level, testing helps public health officials know the disease is spreading and better allow them to direct resources and responses efforts.

I was wrong to ever think that curbing the novel coronavirus could be simple. It is truly a dastardly bug. But I'm confident we can be smarter. Even if COVID-19 doesn't vanish and becomes a seasonal illness, if we give it all we've got, I think we stand a good chance of getting this stealthy virus under control.

Joe Sexton contributed reporting.

There isn’t enough evidence that decades-old anti-malarial drugs work for the treatment or prevention of coronavirus, but here’s what we do know so far.

This article was first published on Sunday, March 29, 2020 in ProPublica.

By Charles Ornstein

President Donald Trump's excitement about decades-old anti-malarial drugs to treat the coronavirus has touched off widespread interest in the medications, hoarding by some doctors, new clinical trials on the fly and desperation among patients who take them for other conditions.

Many experts say there isn't enough evidence that the drugs work for the coronavirus, but at least a few say there's little to lose in giving hydroxychloroquine to patients who are severely ill with coronavirus.

"It's unlikely to worsen COVID-19, and given that it might help ... we have literally nothing else to offer these patients other than supportive care," said Dr. David Juurlink, an internist and head of the division of clinical pharmacology and toxicology at the University of Toronto in Canada.

Here's what we know and don't know about the drugs, chloroquine and hydroxychloroquine, also known by the brand name Plaquenil.

What We Know

The drugs are approved by the U.S. Food and Drug Administration, but not for the treatment of the coronavirus.

The drugs have been around for decades and are approved by the FDA. Hydroxychloroquine has been approved for the prevention and treatment of acute attacks of malaria, as well as lupus and rheumatoid arthritis. Chloroquine is approved to prevent and treat malaria.

At a briefing on March 19, Trump suggested that the FDA had approved hydroxychloroquine for treatment of the coronavirus, which is not accurate. At the same briefing, Dr. Stephen Hahn, the FDA's commissioner said: "That's a drug that the president has directed us to take a closer look at, as to whether an expanded-use approach to that could be done to actually see if that benefits patients. And again, we want to do that in the setting of a clinical trial — a large, pragmatic clinical trial — to actually gather that information and answer the question that needs to be answered and — asked and answered."

That said, doctors are generally allowed to prescribe drugs for unapproved uses.

A number of hospitals are using the drug to treat patients with the coronavirus.

The University of Washington, the University of Michigan and other academic medical centers have added hydroxychloroquine to their treatment protocols. "Hydroxychloroquine is an inexpensive and generally safe drug for short term use, with few drug-drug interactions," the University of Washington protocol says. "While it is unknown if it is effective to treat COVID-19, there is a favorable risk:benefit and cost ratio. Multiple trials are ongoing, and this recommendation will be updated when further data is available."

While Trump has talked about the combination of hydroxychloroquine and the antibiotic azithromycin, also known as Zithromax, the University of Michigan recommends against the use of azithromycin for use in treatment of COVID-19, calling the evidence "weak."

Patients who rely on hydroxychloroquine for other conditions can't get it.

As we reported last week, patients with lupus have not been able to refill their prescriptions. Anna Valdez, a nurse in California, told us that without the drug, she will likely have a disease flare or have to switch to stronger immune suppressing medicines that could, paradoxically, put her at more risk of serious consequences should she contract the coronavirus.

"When I think about the other people out there with lupus and other autoimmune disorders, we're all really scared right now," Valdez said a week ago. "If I get coronavirus, unlike someone else my age, almost 50 years old, who is likely to recover and will be fine, I will likely end up in the ICU."

Trump's unproven claim that hydroxychloroquine could be used to treat COVID-19 has led to hoarding, putting Lupus patients and others at even greater risk. As of Saturday afternoon, Anna Valdez had 27 pills left. That number is now down to 25.

According to a report by BuzzFeed News, health insurer Kaiser Permanente seems to be prioritizing getting the drug to COVID-19 patients above patients with lupus. The insurer told a California patient that it would not refill her prescription for hydroxychloroquine. "Thank you for the sacrifice you will be making for the sake of those that are critically ill; your sacrifice may actually save lives," her doctor's office said in a message.

A Kaiser regional medical director told BuzzFeed that Kaiser, like other health care organizations, "has had to take steps to control the outflow of the medication to ensure access to severely sick patients, including both COVID-19 and those with acute lupus."

She said the decision wouldn't adversely affect lupus patients. "Extensive experience and research show that hydroxychloroquine builds up in the body and continues to work for an average of 40 days even after the last dose is taken. By then, we expect the drug manufacturers to have ramped up production to meet the increased demand."

Some doctors and their families are hoarding the drug.

We reported that pharmacies and state pharmacy boards are concerned about hoarding by doctors and their families.

"It's disgraceful, is what it is," said Garth Reynolds, executive director of the Illinois Pharmacists Association. "And completely selfish."

"We even had a couple of examples of prescribers trying to say that the individual they were calling in for had rheumatoid arthritis," he said, explaining that pharmacists suspected that wasn't true. "I mean, that's fraud."

Some state pharmacy boards have put in place restrictions on prescribing of the drug. And the American Medical Association called on doctors to stop hoarding the drug.

"The AMA is calling for a stop to any inappropriate prescribing and ordering of medications, including chloroquine or hydroxychloroquine, and appealing to physicians and all health care professionals to follow the highest standards of professionalism and ethics," said Patrice A. Harris, president of the American Medical Association.

In a memo to his staff on Thursday, Dr. Craig R. Smith, the chair of surgery at NewYork-Presbyterian/Columbia University Irving Medical Center, responded to the reports of hoarding. "Doesn't that make you proud?" he wrote sarcastically. Instead, he encouraged randomized double-blind clinical trials to assess whether the drugs work.

There are efforts to increase the supply of the drug, but other moves could tighten it.

Several drugmakers have said they plan to step in. Novartis said it would donate up to 130 million doses of generic hydroxychloroquine globally to support the response to COVID-19. Other companies have also pledged millions of doses.

At the same time, the Indian government last week imposed a moratorium on the export of hydroxychloroquine, except under certain conditions including "humanitarian grounds on case to case basis." India is a major supplier of generic drugs used in the United States.

Conservative groups and television hosts are talking up the benefits of the drug.

As we reported last week, a conservative business group is pushing the Trump administration to use hydroxychloroquine, saying in an online petition that "red tape, regulation, and a dysfunctional healthcare supply chain" are impeding the ability of plants in the United States to produce the drug.

The Job Creators Network, founded by Republican political donor and Home Depot co-founder Bernard Marcus, has taken out Facebook ads and texted supporters to sign a petition urging the president to "CUT RED TAPE" and make the drug available.

A nonprofit started by the billionaire co-founder of Home Depot says plants are ready to produce the drug but for "red tape." Experts caution it's unproven and possibly dangerous.

Fox News likewise has been touting the drug. Tucker Carlson said: "Several days ago, the president expressed confidence in hydroxychloroquine as a treatment for the epidemic. That was it for the media. If Trump is for it, they're against it, even if it might save American lives." He added: "What reactive children they are. And they immediately began a sustained push to discredit the drug long before the clinical results were in."

Trump's personal lawyer Rudy Giuliani on Friday tweeted a quote from a conservative activist who falsely called hydroxychloroquine 100% effective at treating COVID-19 and said Michigan's governor was threatening doctors who prescribe it, Mediaite reported. (The drug has not been shown to be 100% effective and Michigan, like many states, has warned doctors against hoarding the drugs for themselves.) Twitter removed Giuliani's tweet because it violated the site's rules.

And cardiac surgeon Dr. Mehmet Oz enthusiastically spoke of the drug on Sean Hannity's Fox News program: "So we don't want people using this stuff willy nilly. You must talk to your physician. But a lot of doctors here in New York and around the country are getting comfortable with the idea of using this earlier in the course of the treatment of their patients."

Clinical trials are underway.

New York state, which has been the epicenter of the U.S. outbreak, has acquired 70,000 doses of hydroxychloroquine, 10,000 doses of azithromycin and 750,000 doses of chloroquine to be used in clinical trials.

"The president is optimistic about these drugs, and we are all optimistic that it could work," New York Gov. Andrew Cuomo said on March 22. "I've spoken with a number of health officials, and there is a good basis to believe that they could work. Some health officials point to Africa, which has a very low infection rate, and there's a theory that because they're taking these anti-malaria drugs in Africa, it may actually be one of the reasons why the infection rate is low in Africa. We don't know, but let's find out and let's find out quickly. And I agree with the president on that."

The University of Minnesota is also enrolling patients in a clinical trial. But it isn't getting enough volunteers, according to ABC News. In a story Wednesday, ABC reported that the lead investigator is seeking 1,500 volunteers for one clinical trial, "but in the week since he obtained FDA approval, he has managed to recruit only 411." Only 25 of 1,500 volunteers needed for a second trial had signed up.

Some people are self-medicating with harmful results.

Banner Health in Arizona reported last week that a man died and his wife was hospitalized after the couple, both in their 60s, took chloroquine phosphate, an additive commonly used at aquariums to clean fish tanks. "Within 30 minutes of ingestion, the couple experienced immediate effects requiring admittance to a nearby Banner Health hospital," the system said.

The man's wife told NBC News that she saw the president's briefings in which he promoted the value of chloroquine and hydroxychloroquine. "I saw it [chloroquine phosphate] sitting on the back shelf and thought, 'Hey, isn't that the stuff they're talking about on TV?'" she told the network. "We were afraid of getting sick."

On Saturday, the Centers for Disease Control and Prevention warned that "chloroquine phosphate, when used without a prescription and supervision of a healthcare provider, can cause serious health consequences, including death. Clinicians and public health officials should discourage the public from misusing non-pharmaceutical chloroquine phosphate (a chemical used in home aquariums)."

What We Don't Know

Whether the drugs are effective at treating the coronavirus.

One small study in France seemed to suggest that hydroxychloroquine, combined with azithromycin, could work as a treatment for COVID-19. A different small study out of China suggests that hydroxychloroquine was not effective in patients compared with those who did not get the medication.

"I think this is an example where the speed of the virus is moving faster than the speed of the evidence," Joel F. Farley, a professor at the University of Minnesota College of Pharmacy, wrote in an email to ProPublica.

Juurlink of the University of Toronto said he supports the use of the drugs in patients with serious illness but not those with mild symptoms or to try to keep people from getting infected.

"I might have a completely different answer a month or two from now once we have better data," he said. "I have no idea whether the advice I'm giving you is good or not, but it's the best I can come up with as of March 27."

Leaders at the Department of Veterans Affairs say they are ready to answer the call to assist HHS or FEMA. But the call has not come.

This article was first published on Friday, March 27, 2020 in ProPublica.

The Trump administration is leaving untapped reinforcements and supplies from the U.S. Department of Veterans Affairs, even as many hospitals are struggling with a crush of coronavirus patients.

The VA serves 9 million veterans through 170 hospitals and more than 1,000 clinics, but it’s also legally designated as the country’s backup health system in an emergency. As part of the National Disaster Medical System, the VA has deployed doctors and equipment to disasters and emergencies in recent instances such as Hurricane Maria and the Pulse nightclub shooting in Orlando, Florida. The VA system has 13,000 acute care beds, including 1,800 intensive care unit beds.

But for the coronavirus pandemic, VA Secretary Robert Wilkie told lawmakers this week that the agency won’t spring into action on its own. Instead of responding to pleas for help from states and cities, Wilkie said he’s waiting for direction from the Department of Health and Human Services or the Federal Emergency Management Agency.

And those calls, for the most part, haven’t come. HHS hasn’t asked the VA for significant help with the coronavirus pandemic. FEMA did not take a leading role in the government’s response until last Friday, and it has yet to involve the VA either.

“VA stands ready to support civilian health care systems in the event those systems encounter capacity issues,” press secretary Christina Mandreucci said. “At this time, VA has not received specific requests from FEMA for assistance.”

The White House referred questions to the VA. The VA referred a question about taking directions from HHS and FEMA to those agencies. HHS referred questions to FEMA, and FEMA referred questions to the VA.

The VA has fielded a handful of limited tasks. It asked 12 health technicians and nursing assistants to volunteer to help HHS and the Centers for Disease Control and Prevention with coronavirus screenings for two weeks in February. The agency sent 14 medical technicians to help HHS with screenings at an Air Force base in California where evacuees from the Diamond Princess cruise ship were being quarantined. And a spokeswoman for CalVet, the state’s veterans agency, told ProPublica that the VA emergency manager in the region has helped provide supplies such as N95 masks.

Lawmakers are frustrated to see the VA largely sitting on its hands as the crisis escalates.

“It is unconscionable that HHS has not utilized every tool it has to address the real suffering of individuals in this nation and called upon VA,” Sen. Jon Tester of Montana, the ranking Democrat on the Senate Veterans’ Affairs committee, said in a March 25 letter to HHS Secretary Alex Azar. “States, communities and patients are already suffering as a result of HHS’s inaction. Get them help now.”

According to the VA’s pandemic plan released on Friday, the agency’s role in the governmentwide response may include helping emergency responders with protective gear, screening and training; helping to staff FEMA’s operations teams; dispatching advisers to state and local public health authorities; supplying medicines and equipment; and helping with burials.

The stimulus deal that the Senate passed late Wednesday includes $27 billion for HHS to reimburse the VA for providing care to the general public. That’s on top of $20 billion to help the VA care for veterans.

Just a month ago, at a House budget hearing, Wilkie declined additional funding. “Right now I don’t see a need for us,” he said. “We are set.”

The VA held its first planning meeting on the coronavirus on Jan. 22, the day after the first case was confirmed in the U.S., according to the agency’s response to an inspector general report released Thursday. But the department did not implement measures until two days after the World Health Organization formally declared a pandemic, on March 11. The VA did not issue guidance on screening patients until March 16.

Wilkie abruptly fired his deputy last month and is under investigation by the VA’s inspector general for allegedly seeking damaging information about a congressional staffer who said she was sexually assaulted at a VA hospital. (He denies doing so.) Wilkie took time off in recent weeks and has taken a back seat at White House task force meetings. Since joining the White House’s Coronavirus Task Force on March 2, Wilkie has spoken publicly only once, on March 18. (Mandreucci said Wilkie has attended 20 task force meetings.) At that time, Wilkie said the VA was preparing to join the disaster response but had not yet engaged.

“We are the buttress force in case that FEMA or HHS calls upon us to deploy medical professionals across the country to meet crises,” Wilkie said. “We plan for that every day. We are gaming out emergency preparedness scenarios. And we stand ready, when the president needs us, to expand our mission.”

Wilkie told Politico the VA was preparing to deploy 3,000 doctors, nurses and other emergency workers but had no timeline.

The VA’s role as the country’s emergency medical backup was first established by Congress in 1982 and is known as the agency’s “Fourth Mission.” (The first three missions are sometimes identified as care, training and research, and other times as health, benefits and memorials.) This month, a description of this Fourth Mission was suddenly scrubbed from the website of the VA’s Office of Emergency Management. Mandreucci noted it appeared on a different page.

The VA’s ability to support FEMA could be limited by demands from its own patients, who are largely older and part of the demographic that’s most vulnerable to the coronavirus. As of Friday, the VA had 571 patients who tested positive and nine who have died.

The VA’s inspector general said in a report on Thursday that health center leaders reported concerns about running out of medicines and protective gear. Leaders at the VA hospitals in Durham, North Carolina, and Detroit said they needed more ventilators. The inspector general’s report said 43% of the facility leaders surveyed planned to share ICU beds or protective gear with local providers.

“That assistance is dependent upon the availability of resources and funding, and consistency with VA’s mission to provide priority services to veterans,” Wilkie said in a March 23 letter to lawmakers.

Administering coronavirus tests requires time and supplies that are already running out. But aggressive testing has proven to be the best way to track and isolate the disease, stopping its spread. The best path forward depends on where you are.

This article was first published on Monday, March 23, 2020 in ProPublica.

There's a seeming paradox in experts' advice on testing people for COVID-19. A growing number of epidemiologists are calling for a nationwide regimen of tests to identify hot spots and allow public health workers to isolate the close contacts of anyone who's infected.

Yet New York City, the epicenter of the outbreak in the U.S., has ordered doctors not to test anyone who is "mild to moderately ill" with COVID-like symptoms, a position also taken by Los Angeles. As New York's Health Department succinctly put it: "Outpatient testing must not be encouraged, promoted or advertised."

Dr. Tom Frieden, former health commissioner of New York City and former head of the Centers for Disease Control and Prevention, said both viewpoints make sense.

"Where you stand depends on where you sit," Frieden said. "Local context is all important. In New York City, today, you should not get tested if you have mild symptoms."

The reason, he said, is that the health care systems in places like New York, Los Angeles and Seattle are about to be overwhelmed by a wave of people seriously ill from COVID-19. They know it's coming. Administering each test takes up protective gear, swabs and health care workers' time, all of which should be reserved for patients with life-threatening conditions. On Monday, for instance, NewYork-Presbyterian Hospital reported that it had more than 600 patients with COVID-19.

Conversely, Frieden and other experts pointed out, the United States will need to pursue a policy of very broad testing if it hopes to slow the spread of the disease and restart parts of the economy anytime soon. Frieden noted that one of the countries most effective in lowering its infection rate, Singapore, had great success in tracing and isolating the contacts of each infected person. That is no longer possible in New York state, which has reported more than 20,000 positive tests and has many times that number of people infected. But he said it remains doable in many other cities and towns.

"In places where you've got the cases way down, or there are no cases," he said, "aggressive testing will be needed."

The lack of testing continues to be a source of deep frustration across the country, with worried patients unable to find out whether they have the ordinary flu, the coronavirus or something else entirely. The availability of testing in regions that aren't hot spots still faces an array of bottlenecks, from shortages of cotton swabs to the capacity of the labs processing the tests.

Dr. Scott Gottlieb, the former head of the Food and Drug Administration under President Donald Trump, argued in a widely read Twitter commentary for a multipronged approach to fighting the virus, which will involve overcoming all of these hurdles and significantly stepping up testing nationwide. The current "shelter in place" orders, which have tens of millions of people in New York, California and other states limited to their homes and not going to work, he said, will ultimately have to be supplanted by a more targeted approach.

To do this, he wrote, the United States "must widely test our population" and "diagnose mild and even asymptomatic cases" with reliable tests that can be administered in doctors' offices. "We must have tools to identify and isolate small outbreaks so we can lean less heavily" on locking down whole swaths of society, Gottlieb wrote.

Trevor Bedford, a University of Washington virologist who has been directly involved in detecting and fighting his state's outbreak, offered a similar prescription in a recent series of tweets. Bedford's observations were prompted, in part, by a recent study by epidemiologists at Imperial College London that said countries had little alternative to maintaining strict restrictions on social contact until a vaccine is available, a process that could take 18 months. The study forecast as many as 1.1 million to 1.2 million deaths in the United States if officials backed off the sorts of measures taken by New York and California in recent days.

Bedford said he was not that "pessimistic," and he called for a strategy that "revolves around a massive rollout of testing capacity." Recent studies, he wrote, support the argument that a "significant" portion of the transmission of the virus arises from people who spread it before they feel sick. There also are people who infect others while never experiencing any symptoms of their own.

Something approaching universal testing would make it possible to significantly reduce such "transmission routes."

"If someone can be tested early in their illness before they show symptoms," Bedford wrote, "they could effectively self isolate and reduce onward transmission compared to isolation when symptoms develop."

He envisaged a future in which swabs are delivered to people's homes for quick return and in which drive-through testing is widely available to anyone with a car. "There are logistics involved in getting a result quickly," he wrote, "but it's really just logistics, which can be solved."

Bedford suggested an approach that appears to have worked in South Korea, which combined test results with "cell phone location data" on known positive cases, allowing notification of people who have been in proximity to confirmed cases to "self isolate and get tested."

A third pillar of Bedford's approach is a medical exam that does not yet exist — a blood test that can detect the presence of antibodies to COVID-19. Antibodies are created when the immune system successfully fights off an infection and people with them are "highly likely to possess immunity" and can "fully return to the workforce and keep society functioning."

That assumption, like many about the virus, remains the subject of research. For his part, Frieden said he was cautious about taking any action based on a test that detects antibodies. Does it mean the person is immune from a second infection? "We can't count on that," he said. "We don't yet know that."

The clash between the short-term and long-term views of testing were on vivid display in the press conference last week that made headlines for Trump's angry outburst at an NBC reporter.

Earlier in the briefing, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, sought to distinguish between the ultimate need for more tests with the immediate requirement that Americans stop gathering in workplaces, bars, streets and restaurants.

The extreme steps taken by California and New York, Fauci said, are "how you put an end to this outbreak."

"Testing is important," he said. "But let's not conflate testing with the action that we have to take. Whether or not you test, do this. I'm not putting down testing as an important issue, but people seem to link them so much that if you don't have universal testing, you can't respond to the outbreak. You really can."

Trump disparaged the notion of widespread testing as imagined by Bedford and others. "We don't want every American to go out and get a test. Three hundred and fifty million people," Trump said. "We don't want that. We want people that have a problem, that have a problem with they're sneezing, they're sniffling, they don't feel good, they have a temperature."