Could Rapid Antigen Testing Be NPHET's Final Undoing?

In February, 12 large Canadian companies joined forces to trial mass rapid testing in their workplaces as a potential route to the reopening of their business.

In March, 5,000 people attended an indoor concert in Barcelona with the help of rapid antigen tests and only two infections were traced to the event.

Universities in the USA have been using rapid antigen testing as part of their campus surveillance programs for several months, while the government is now sending free rapid tests to residents in North Carolina as part of a pilot study.

Germany has offered free rapid antigen tests to members of the public, as have the Brits, who are also leading research into rapid testing in second-level schools and have recently deployed rapid testing as part of their local surge testing programs.

All over the world, countries are experimenting with rapid antigen testing. They are running trials, collecting the data, analysing the results and using their findings to guide policy. In simple terms, they are teaching themselves how to use this new tool, and they will put it to use for the benefit of their citizens.

These may be national efforts, but they bring global results. Not only are these nations learning how to protect themselves from COVID-19 (and therefore their neighbours too), they are also making valuable contributions to the world’s nascent understanding of this new testing technology, and at a time when those findings can immediately be put into practice.

And yet, Ireland’s policymakers are unmoved. Rapid antigen testing has not played a meaningful role in Ireland’s pandemic response and it is unlikely to do so in the near future. NPHET must be particularly unimpressed by the international community’s efforts. They continue to maintain that PCR testing and lockdowns are the only way to manage this crisis (a belief shared by their associates in ISAG) despite the fact that both policies have been in place for well over a year now and seem to have achieved little more than adding to the nation’s suffering.

Given that neither the media nor the government have found the courage to seriously question NPHET’s seriously questionable stance on testing, the people (and not for the first time in this crisis) are left to work it out for themselves. So, how do we explain the gap between NPHET’s alarmist position on rapid antigen testing, and the more sensible one that is developing in workplaces, in society, online, and most importantly, in the scientific literature?

To answer that question, it will help to understand the professional backgrounds of NPHET’s members – their skills, their workplaces, how they’ve been trained, and what they value – because these cultural factors will go a long way towards explaining their difficulties with rapid antigen testing, and with contagious diseases in general.

The ‘Medics’

NPHET’s members are senior medical professionals who have been drawn from the alphabet soup of Ireland’s medical establishment (the HSE, HSPC, HIQA etc) along with some experts and consultants from the private sector. There is a diversity of medical skills and experiences present in this group but for the sake of convenience, I will refer to them as ‘Medics’. It is a crude categorisation, but they do share important traits.

Firstly, Medics are trained to cure individual patients. That means they perform diagnostic tests to identify the cause of the patient’s illness, and with that information they determine the appropriate course of treatment. Medics provide an essential service to society, and I wouldn’t even want to imagine life without them, but as their focus is primarily on the health of individuals – not groups or communities – their training and expertise do not translate well to the management of a contagious outbreak, as this piece will argue.

Over the course of their training – which can last for a decade or more – Medics will sit numerous exams, and much of their preparations will be spent memorising the many physiological definitions and classifications that describe the human body. This is an unavoidable part of any Medic’s training, but it comes at a cost. Years of rote memorisation can leave one with a deterministic mindset. Causes are linked to effects by clear straight lines, while ideas are either correct or incorrect, so there is less room for discussion or interpretation. This leads to intellectual rigidity, and they can become slow to adapt to new or changing circumstances.

When they have passed their exams, some Medics will go on to work in clinical settings where they consult with patients, perform diagnostics, and prescribe treatments. Others join hi-tech laboratories, where they run complicated tests with precise instruments and expensive machinery. For most medics, these clean, modern facilities with their advanced medical technology and teams of highly trained professionals are their natural habitats. This is what they know. This is where they feel most comfortable.

How Does That Explain NPHET’s Preoccupation with PCR Testing?

The Medics of NPHET were attracted to the PCR test for a number of reasons.

Firstly, the PCR is a diagnostic test. The diagnosis of patients is one of the Medics’ primary functions, so they already had the practical understanding of how the tests should be performed and the wider appreciation of the role diagnostics play in health care. The PCR fit neatly into their existing understanding of the world, so they were comfortable with it. The PCR was safe territory for them.

The PCR has earned the title of the ‘gold standard’ of diagnostic testing because it is the most accurate of all the diagnostic tests. It is the best at finding the SARS-COV-2 virus when the sample is truly infected (‘sensitivity’) and the best at not finding any virus when the sample is not infected (‘specificity’). As the gold standard diagnostic, the PCR test was the obvious place for NPHET to start their research into COVID-19 testing (start, not finish).

Finally, the PCR is a well-established laboratory process that has been in operation for 20+ years. NPHET knew that the equipment and infrastructure were already in place, and that their staff were trained and experienced. Moreover, each step in the PCR process – from sample taken to result received – took place within the health care system, so NPHET would have had oversight over the whole operation. PCR testing wasn’t just safe territory – it was home soil.

The Medics of NPHET didn’t consciously choose PCR testing so much as they naturally gravitated towards it. The PCR made the most sense to them. It aligned with their professional grounding in precision diagnostics and clinical healthcare. It was the easiest to implement, and many of NPHET’s members already had first-hand experience with at least some part of the process, from sample to result. There was no suggestion that the Medics would have to do any extra research, or delve into areas in which they weren’t already the experts. At a fundamental level, NPHET were comfortable with PCR testing, and that is why they defaulted to it.

The convenience of the PCR process lay in stark contrast to NPHET’s understanding of rapid antigen testing.

What Was NPHET’s Problem With Rapid Antigen Testing?

The technology supporting rapid antigen testing has existed for decades, but it had been newly repurposed to test for SARS-COV-2 antigens. As a result, there was little historical data on its performance, and this was a problem for the Medics. They had been taught to expect multiple peer-reviewed studies based on randomised controlled trials in support of any proposal or change of procedure. Their scientific grounding would not allow them to accept anything less. But without the papers on which they would normally lean, NPHET felt uncomfortable rapid antigen testing, so they decided instead that it would be unscientific for Ireland to experiment with it.

There may have been an element of intellectual snobbery in the decision too. The Medics had been trained on precise instruments and with tests so accurate that they only needed to be performed once. Rapid antigen testing, on the other hand, was performed with a low-tech, plastic and paper lateral flow device, and the tests needed to be performed in high volumes to provide any value. The Medics probably couldn’t understand why anyone would want to use something so basic and so obviously inferior, especially when they had access to the Nobel prize-winning PCR technology.

At the core of NPHET’s problem with rapid antigen testing was the fact that the PCR process was a diagnostic test, whereas the rapid tests were not. The Medics – steeped in diagnosis – could only understand the rapid tests as diagnostics, and therefore as a substitute for the PCR. And from that perspective, they were correct: the PCR process is clearly the superior diagnostic. But testing isn’t just about diagnostics, and we are not bound to choose one test over the other in all circumstances. There are multiple roles for testing in a pandemic, and all should be explored.

The low sensitivity of rapid antigen testing relative to the PCR left NPHET further entrenched in their position. When you are trained in diagnosis, everything takes a back seat to accuracy. It makes sense too. Doctors and patients would be equally happy to wait another week or more, if it would make the diagnosis of a disease like cancer more reliable. In that context, the sensitivity of the test is paramount, and concerns about cost or turnaround time are trivial. But COVID-19 isn’t cancer, and rapid antigen testing isn’t a diagnostic. This virus has a shorter lifespan, and it moves quicker. Ireland needed tests that could keep up with it.

The final problem with rapid antigen testing – from the Medic’s perspective – was that it was so simple, almost anyone could do it. It could be performed by untrained individuals, from the comfort of their own homes, in less than half an hour, and without any input from the health service – including NPHET. If the lower accuracy wasn’t enough to put the Medics off, the threat rapid testing posed to their control over the nation’s response would have sealed the deal.

Everything about rapid antigen testing was alien to NPHET. They weren’t taught about it in university, it didn’t align with their professional experiences and values, and it could only ever reduce their status and power. There was nothing in it for them. Sure, there was plenty of research to support the idea that cheap, high-volume testing could suppress transmission without placing an intolerable burden on the people but, despite what they projected, NPHET weren’t interested in the latest research. The group’s decisions were being driven by their own comfort and convenience far more than any science, and since rapid testing would have pushed them out of their comfort zone, they stood in the way of any attempt to see it implemented.

The Emperor Has No Clothes

There is no one test or one approach to testing for COVID-19 that is correct or appropriate in all circumstances. Each test has its own strengths and weaknesses, and these differences present opportunities, not traps. NPHET’s summary dismissal of rapid antigen testing reveals a lack of understanding of the different roles testing can play in a contagious outbreak, but it also points to a lack of leadership and industry within the group.

There was never any need to research if rapid tests would work in Ireland (we had more than enough data to see that they did), what was needed was a discussion of how to make them work. NPHET should have realised that the real challenge was to build a national testing program that could combine all available testing technologies and put them to the best possible use. The structure of the testing program (the tests, where they were performed, their volume and availability, costs) mattered more the accuracy of the individual tests, and that was where NPHET’s attention and resources should have been directed.

But NPHET never really understood that challenge. All of this was new to them. Like inflation and the business cycle, our enlightened technocracies were assumed to have evolved beyond the threat of contagious diseases. These pathogens were regarded as developing world problems – ‘diseases of poverty’ – and of little relevance to a sophisticated, global economy like Ireland’s. Our Medics had received little training in the prevention or management of contagious outbreaks and, naturally, the lack of structure or direction in Ireland’s COVID-19 response was as inevitable as it was plain to see.

The key insight that eluded the Medics, was that contagious diseases don’t infect individual people, so much as they infect whole populations. The disease is its spread, and the danger is in its cumulative effects, not in the risk it poses to any one individual. The Medics needed to shift their mindset from individual health to public health, from diagnosing infection to diagnosing infectiousness, and from testing people to testing the population. Had they done so, they would have leaned on testing as their main policy tool (instead of lockdown), and mass rapid antigen testing would have played a central role in the nation’s response.

Unfortunately, NPHET couldn’t see it. No one had ever told them how to test whole populations. Hamstrung by an education that trained them to think deterministically and at all times ‘inside the box’, NPHET stuck to what they knew best. Rather than using a test designed for screening populations, they took a test designed for diagnosing individuals and then tried to scale it up to the population level. It was a bad idea in theory and in practice. The results were too slow, the test capacity was limited, and the test accuracy was spurious. Time was wasted, people were forced into unnecessary isolations, the national lockdown continued far beyond any reasonable point, and the cost of it all was obscene.

But NPHET had made its decision, and without the intellectual flexibility (or humility) to reassess their position, the error became permanent and normalised in our response – just as the virus became permanent and normalised in our society.

Will NPHET Face a Reckoning?

Philip Nolan’s response to Aldi’s tweet advertising home testing kits may have been immature, snide, or an overreaction in the moment, but given the consistent messaging from NPHET before and since, there can be no doubt about NPHET’s distaste for rapid antigen testing. And while the failure to see the potential uses for this novel process is only their latest policy error, it could prove to be the most significant.

What the furore over rapid testing has exposed more than anything, is the fact that NPHET never really understood the nature of the problem they had been assigned to solve. To prioritise test accuracy over speed in a pandemic is probably the worst mistake they could have made. Contagions build exponentially and can quickly get out of hand. It is essential that the health response can get ahead of the disease and stamp it out as quickly as possible. In this context, test speed, cost, frequency and availability are collectively more important than accuracy.

Worse still, the group’s monoculture and its deference to seniority prevented it from realising – much less correcting – the inevitable errors. Like bad gamblers who’ve seen the market go against them, NPHET doubled down on their PCR position and tried to tough it out. Rather than adapting to the new and evolving situation, NPHET condemned the whole country to a strategy that they should have known could not work. This was anything but scientific but, as noted above, it was never about the science.

The cause of rapid testing was not helped by the fact that it posed a threat to NPHET’s authority. If the people could test themselves and manage their own health outcomes, then why would anyone need NPHET? I am hardly alone in thinking that the fear of a potential loss of control explains much of the fire and brimstone that has come from NPHET on rapid testing in recent weeks.

But NPHET should be careful, because they are playing a very dangerous game. They may find that the vitriol with which they have attacked rapid testing could come back to haunt them.

The data supporting rapid antigen testing is growing by the week (even the EU seems to be coming around to it) and an increasing number of Irish people believe it to be an effective policy tool. Those people might reasonably ask themselves: if we can understand rapid testing, why can’t NPHET? And if NPHET can be so emphatically wrong about rapid testing, where else might they have led us astray?

Rapid antigen testing has the potential to become the domino which sets in motion a period of national reflection which itself leads Irish society to address important questions which have hitherto been ignored by the media, in particular: how much of our suffering over the last 18 months was avoidable, and how much of it was a result of NPHET’s errors?

If those questions receive serious scrutiny in the media, then I think there will be a significant reassessment of NPHET’s role in this crisis. If the Irish people come to realise that their sacrifices were unnecessary and unjustified, and that the misery they have experienced in this crisis was forced upon them by a group of Medics who never had the ability to solve the problem in the first place, we may see a wave of anger crash over the nation that takes us back to 2011.

If that happens, it will be the Medics of NPHET who will need a period of self-isolation – and for a lot longer than 14 days.