113 billion COVID tests to reopen India

India faces economic devastation of epic proportions as a result of the national lockdown that was imposed last month, now extended until the end of April. The economic costs of continuing total shutdown are vast all over the world, yes, but while the developed world trades off money for lives, in India, the calculus of economics has always been denominated in human bodies -- we are not sacrificing our economy for lives, but rather lives for other lives. The longer total lockdown is sustained, the more likely it becomes that the sheer humanitarian cost of the long-term economic devastation to follow will exceed even that of an unfettered coronavirus epidemic.

There is precisely one way to guarantee a near-total economic reopening before a vaccine or effective therapeutic solution is identified -- comprehensive daily testing sustained for a number of 14 day cycles. Given a test that can return a result quickly enough -- a few hours would suffice -- every individual could be tested every day before they go to sleep, and would know whether they needed to self isolate once they wake up. This will stop the virus in its tracks, and eliminate the need for any sophisticated contact tracing or surveillance. How many tests would be necessary? 6 cycles is 84 days, and for our population of ~1.35 billion people, that’s about 113 billion tests.

This might seem ludicrous, since this is at least four orders of magnitude greater than the total number of tests conducted worldwide so far (< 10 million). It is indeed unlikely that existing RT-PCR testing can scale to this level, not least given the distributional hurdles of moving all of those samples around. Our best bet is a test that returns a result at home without needing to be returned to a lab for processing. Luckily for us, there are a number of candidates for such a test, including an Indian-developed paper-based antigen test out of CSIR Institute of Genomics and Integrative Biology. The scientist behind this work, Dr. Debojyoti Chakraborty, says it would cost Rs. 500 to make per test. That’s 6 USD. Can this cost be brought down at scale? These tests operate somewhat similarly to and have similar manufacturing needs to pregnancy tests, which in India wholesale for Rs. 5 (0.066 USD) per test, and on Alibaba in China go as low as 0.001 USD (Rs. 0.076) per test. Taking even the higher of those two numbers, the total cost of manufacturing 113 billion tests would be 7.26 billion USD, or Rs. 55304 crore. The Modi government’s phase 1 economic stimulus is Rs. 170000 crore (22.5 billion USD), and the Indian economy is expected to lose 4.5 billion USD every additional day of the lockdown. Even if the development of a paper based test were to cost $20 billion in addition to the 7.26 billion manufacturing cost, it would still be worth it if it shortened lockdowns by just a week. The numbers are staggering and clear -- the government should throw everything they at validating and mass-manufacturing some kind of at-home diagnostic.

Savvier readers will point out that I haven’t addressed issues of accuracy and sensitivity -- in other words, what the false-positive and false-negative rates of these tests would be. One might think that if they’re not perfect or very close to it, comprehensive testing will not solve the crisis. Indeed, this seems to be the WHO’s position. Nobel-prize winning economist Paul Romer has run a series of simulations that suggest that such concern is misplaced -- even a truly bad test, one which fails to detect 80% of infected people tested, can reduce the fraction of the population eventually infected by half, massive reducing load on the healthcare system, and a test which fails to detect 80% of all infected people tested can bring the percentage of people ultimately infected down to a third or fourth of what it would otherwise be.

Moreover, setting up the production capacity to manufacture tests at this scale will create millions of jobs directly and indirectly, as well as endow India with cutting-edge knowhow in the mass production of novel biotech of this kind (the paper based test I linked to uses CRISPR-Cas9 gene editing). We’re already well placed to do this given our status as the world-leader in generic pharmaceuticals, with much richer countries like the United States leaning on our drug supply chain to prop up their healthcare systems. Indeed, given that there is likely to be massive global demand for these tests if we can ramp up capacity fast enough, this testing program may well pay for itself many times over.

If we do this right, this could be our Apollo program, planting the seeds of million biotech and medical companies building off the knowledge of people who participated in this era-defining project, setting us to benefit from the likely growth of the medical market in the aftermath of this pandemic. If we’re going to do this, we should start now -- every day wasted is millions of lives and livelihoods shattered beyond repair.

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Soham Sankaran is the CEO of Pashi, a Y Combinator-backed startup building software for manufacturing. He was previously a doctoral researcher at Cornell in Computer Science, and a researcher at the Yale Institute for Network Science working with Professor Nicholas Christakis on human social networks. He has a BS in Computer Science from Yale University.

Soham can be contacted at (his first name) [at] soh.am.

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