What If We Couldn’t Diagnose Infectious Diseases?

It’s six a.m., and both your electric alarm clock and your furry, slobbery alarm clock have been haranguing you for half an hour to get up. You can hit the snooze button on one, but the other demands to be fed (and let outside). But this particular morning, you’ve woken up with a sore throat after tossing and turning all night, continually sweltering and then freezing.

You stumble out of bed and into your morning routine, pouring kibble into the dog’s food bowl with one hand and balancing a thermometer in your mouth with the other. After a few minutes, the thermometer beeps. 101 °F (38,5°C). You fire off an email to work letting them know you’re taking a sick day, and then call the doctor.

At the doctor’s office, they suspect you have “strep” (a throat infection caused by Group A streptococci), so they swab your throat and run an in-office test that takes about 30 minutes. It comes back positive. Your doctor prescribes a course of antibiotics to treat your strep infection and sends you home, with an admonishment to take the full course and stay home from work for at least the next 24 hours. Within a couple of days, you start to feel better, and by the time you finish the antibiotics, you’re back to normal and not quite so annoyed with your furry alarm clock for jumping all over the bed at five-thirty in the morning.

Now, replay this scenario, except that the doctor has no way of testing you for infection. All she has are your symptoms, which are broad enough that they could indicate a range of ailments. Without diagnostics, she must try to guess what’s making you sick. Her guess may or may not be right, and you may or may not get the right treatment. You may get unnecessary or the wrong antibiotics with side effects, and you may not recover as quickly or as fully. 

Fundamentally, doctors are blind without diagnostic tools. “It’s like looking for someone in a cave without any light,” says Dr. Mark Miller, Chief Medical Officer at bioMérieux. “You have no idea where you are.”

That explains why 70% of medical decisions are made based on results from diagnostic testing. Yet, such tests account for only 3-5% of all healthcare spending. That’s an enormous return for a comparatively small investment.

Patients in developed countries, particularly those in highly populated metropolitan areas, benefit significantly from diagnostic testing, but diagnostic tools are frequently difficult to access or completely unavailable to people in rural areas or developing nations. Accessibility depends on a variety of factors, but patient distance to the nearest hospital or clinic and financial resources available to healthcare providers and systems are especially important.

Those of us who live in countries and locations where diagnostic tools are readily available, both at the point of care, and with advanced diagnostics found in laboratories, often take those tools for granted. We focus our attention on treatment instead, as we understandably want whatever is ailing us to be cured. But without diagnostics, treating even basic infections with the appropriate medications becomes difficult if not impossible.

Similarly, patients in nations with universal healthcare systems often have easier access to diagnostics. Conversely, where universal healthcare has not been implemented, patients’ financial situations can prevent them from seeking medical care as well as adversely impact the quality of care they receive.

Before the COVID-19 pandemic, the World Health Organization and the World Bank estimated that more than half a billion people were pushed or further pushed into extreme poverty (defined as living on less than $1.90 per day) because they had to pay for health services. This is a situation that is likely to have been aggravated by the COVID-19 pandemic, which has wiped out years of international efforts by substantially disrupting health services.

The commitment made by all UN Member States to achieve universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals, remains unchanged, but the steps to reach the objective have grown.

UHC does not mean free coverage for all possible health interventions regardless of cost, because that would be unsustainable. Instead, the goal of UHC is to give everyone access to good-quality services that address the most significant causes of disease and death. Diagnostics, especially those that test for the most common infectious diseases, are a major part of those services.

In 2020, the WHO released its third edition of a Model List of Essential In Vitro Diagnostics. The list specifies tests recommended for primary healthcare and for facilities with clinical laboratories.  It provides an important framework that countries can adopt and adapt to their needs.  While point-of-care tests used in primary healthcare have become more readily available in developing nations and rural areas, with excellent results, investments in advanced diagnostic tools and laboratories for these communities remain scarce.

The authors of The Lancet Commission on diagnostics, transforming access to diagnostics write that, “…despite diagnostics being central to health care, access to diagnostic testing in pathology and laboratory medicine (PALM) is poor and inequitable in many parts of the world.” The researchers suggest that the consequences of diagnostic inaccessibility—namely mortality and morbidity—could be substantially improved if gaps in access to diagnostics were reduced.

However, closing those access gaps “…will require a multifaceted approach, ranging across policy, regulation, financing, workforce, and infrastructure.” Microbes do not adhere to international borders.  Without the appropriate diagnostic tools deployed around the globe, we will continue to struggle with disease outbreaks and with addressing antimicrobial resistance, regardless of where we live.

And that strep infection? It could be resistant to antibiotics, but without diagnostics, you would never know.