vox--2020-08-27--Rapid $1 Covid-19 tests exist. Why can’t we get them?

To get the US pandemic under control , a growing number of health and medical experts are making a clarion call for an additional testing approach to Covid-19 .
What we need , they argue , are at-home rapid tests that look for antigens , proteins the live virus makes .
These kits would allow anyone to test themselves for the coronavirus any time ( and anywhere ) for between $ 1 and $ 5 , and get results in about 15 minutes .
No doctors , labs , expensive machines , or special chemicals required .
“ I see @ @ @ @ @ @ @ solution that ’ s literally sitting in front of us , ” says Michael Mina , an epidemiologist at the Harvard T.H .
Chan School of Public Health , who has led an effort to get these rapid tests authorized by the Food and Drug Administration .
“ We could be getting massive outbreaks down to nothing .
...
It ’ s a no-brainer to me.
” Back in April , Deborah Birx , the White House coronavirus response coordinator , actually called for just this sort of solution in an interview on @ @ @ @ @ @ @ to have a breakthrough innovation in testing , ” she said .
“ We have to be able to detect antigen.
” Several small companies have been developing these simple tests , and the conglomerate 3M is working with MIT on another one .
( The new BinaxNOW test from Abbott , authorized August 26 , is different — it requires a health professional to administer it , and the patient must have symptoms to get a prescription . )
And some of these at-home tests are ready to go .
But they @ @ @ @ @ @ @ unused , for months .
Why ?
The holdup is that rapid , over-the-counter antigen tests are not nearly as sensitive to the coronavirus as the molecular PCR ( polymerase chain reaction ) tests currently used for most Covid-19 testing .
In fact , by PCR standards , some at-home antigen tests might catch only half or a third of people who test positive on a PCR test .
But that ’ s because they ’ re looking for different things in different ways .
A PCR test , designed to diagnose an @ @ @ @ @ @ @ low levels of viral material before or after a person spreads the virus .
An over-the-counter antigen test , meanwhile , relies on high levels of the virus to be able to detect it .
These high levels , though , also happen to coincide with when a person is most likely to transmit the virus to others .
“ The antigen test is maximally sensitive at the same time that you are maximally infectious , ” says David Paltiel , a professor of public health and health policy at the Yale School @ @ @ @ @ @ @ test is picking up the infections I want .
Because I don ’ t care about infections , I care about infectiousness.
” Since at-home antigen tests would be fast and cheap , they could allow people to test themselves regularly .
Currently , PCR testing is relatively expensive ( about $ 100 ) and often experiences processing delays that hamstring efforts to stop transmission .
PCR tests ’ sensitivity , however , is the current benchmark by which the FDA judges new tests for emergency authorization .
This pre-pandemic framework , Mina @ @ @ @ @ @ @ as we look for the most effective tools to fight the coronavirus right now .
So they are calling for a new way to evaluate these tests , one based in public health terms rather than individual diagnostic ones — in other words , widely accessible tests that are well tuned to find those who are most likely to spread the virus .
Let ’ s take a look at how and why this potential solution has gotten sidelined in the pandemic battle — and what might be done to get these tests @ @ @ @ @ @ @ the public .
To understand the stalemate around antigen tests , it ’ s helpful to first understand what they are , how they differ from classic PCR tests , and the trajectory of coronavirus infections .
First : An antigen test looks for a particular protein from a live virus .
( Not to be confused with an antibody test , which finds immune cells your body has made after mounting a defense against the virus . )
These tests need a lot of viral material to generate a positive result .
@ @ @ @ @ @ @ the virus ’ s genetic material — its RNA — making copies of itself until it reaches a detectable level .
As a result , it has a fairly low ( although not perfect ) false-negative rate , or the proportion of time it would tell someone who has the virus that they don ’ t .
Finally : One of this new coronavirus ’ s superpowers is its ability to spread from people before they start to experience symptoms .
In fact , people tend to carry the most live virus the @ @ @ @ @ @ @ sick , and the amount tends to quickly trail off in the several days after symptom onset .
So proponents of at-home antigen testing say that PCR tests , while useful in determining whether an individual is infected with Covid-19 , are actually a poor tool in finding people who are most likely to spread the virus .
That ’ s because PCR tests are so sensitive , they are excellent at picking up traces of the virus even after someone has beat it back and is no longer infectious .
Thomas Tsai @ @ @ @ @ @ @ Harvard T.H .
Chan School of Public health , compares the two types of testing this way : PCR tests are reactive tests , usually used for people who either have symptoms , a close contact with the virus , or other reason to think they are likely to have caught it .
Rapid , widespread antigen tests are proactive tests , designed to find cases before they spread the virus more widely .
And as the Center for Evidence-Based Medicine noted earlier this month , “ while an infectious stage may last @ @ @ @ @ @ @ degrades slowly over time , it may still be detected many weeks after infectiousness has dissipated.
” To look a little bit deeper at how this works , an August 7 preprint report which hasn ’ t been peer reviewed proposes that people with 10,000 copies of the virus detected in their airways are unlikely to spread the virus to someone else , even with sustained contact ( according to their models , it would happen about 0.002 percent of the time ) .
Once that viral load climbs to 10 million copies @ @ @ @ @ @ @ about a day ) , they have about a 40 percent chance of transmitting it to a close contact — and about 80 percent chance at 100 million viral copies ( it ’ s worth noting that when they first reach this level they still might not have any symptoms ) .
By the time someone has had Covid-19 symptoms for several days ( which might currently be about the time they receive results from a PCR test ) , however , the amount of virus in their system has likely waned to @ @ @ @ @ @ @ .
As the authors of the study note , “ transmission after the first week of infection is quite rare.
” At that point , says Mina , it ’ s more likely that “ they just have residual [ virus ] RNA hanging about.
” So although many of these people would get a positive PCR test — and a negative at-home antigen test — they are much less likely to transmit the virus than someone who feels fine now but will develop symptoms in a day or two .
“ The @ @ @ @ @ @ @ , ” Paltiel says .
“ The PCR is just picking up strands of viral junk.
” If your goal is to slow an outbreak , he notes , this sort of data is not actually that useful .
“ Outbreak control is all about figuring out who ’ s actually spreading this stuff.
” This could also help explain why so many people continue to get positive PCR test results weeks after getting over most of their symptoms .
One small JAMA study , for example , found that one in six @ @ @ @ @ @ @ positive for the virus via PCR test four to 24 days after being discharged from the hospital .
As an author of a commentary about that paper noted about these long-tail positive test results , “ the clinical significance and infectivity are minimal .
These PCR tests likely are responding to noninfective RNA fragments and do not represent detection of viable virus.
” Antigen tests , however , need a much higher level of the virus to register a positive result because they don ’ t rely on multiplying their target .
This @ @ @ @ @ @ @ matched for finding people with Covid-19 at precisely their most infectious points rather than potentially long after symptoms have arrived and infectiousness has faded , as is more likely now with the long delays in PCR results and contact tracing .
As Paltiel describes it , the concept is pretty simple : “ The more viruses around your airway , the more likely you are to be a risk to others.
” According to an analysis from the June preprint ( on which Mina was a co-author ) , this crucial time period @ @ @ @ @ @ @ most sensitive : detecting viral load at around 10,000 copies , which is just before someone ’ s infectiousness skyrockets .
PCR tests , on the other hand , can pick up about 1,000 copies of the virus , which gives them about a day ’ s head start at finding the virus .
Although with a lag of more than a day in returning results , that benefit is lost .
To put it in other terms , these tests could be “ superspreading detectors , ” Mina says , locating many @ @ @ @ @ @ @ to unknowingly infect many other people before they know they have the virus .
“ Their whole goal is to capture the 90 percent of people who might be transmitting the virus , ” Mina says .
So if they were to be evaluated in this population — those with high levels of the virus — he says , the sensitivity for these tests would soar from 30 or 50 percent ( as measured against PCR ) up to 95 percent .
( They also have very low false-positive rates , in which @ @ @ @ @ @ @ virus when they actually didn ’ t . )
Another selling point to antigen tests , proponents argue , is that they would give people their results much faster than PCR tests .
Since delays of more than a day or so in getting PCR results back make containment and tracing much less effective , being able to have results back in 15 minutes or so would be a vast improvement .
“ Of all the variables that we control , the frequency of screening is the most important ” Because these tests @ @ @ @ @ @ @ could also test frequently , which could help overcome worry about the tests being less sensitive than PCR — especially in the very small window early in an infection when a PCR test might catch the virus but an antigen test wouldn ’ t .
And such frequent testing would be far superior to the still relatively rare PCR testing that we ’ re currently doing , Paltiel says .
“ Of all the variables that we control , the frequency of screening is the most important , ” he says .
Even @ @ @ @ @ @ @ of all cases ( regardless of infectiousness level ) , he says , if it ’ s “ between a test that is missing 50 percent [ but rapid and easy ] and a test that is getting everyone that is so expensive or so cumbersome or has such a long turnaround time that it takes a week , I ’ ll take what ’ s behind door No .
1.
” In the June preprint study , the researchers found the sensitivity of a test made little difference in the rate at @ @ @ @ @ @ @ .
For example , running either of these tests , PCR or at-home antigen testing , on a population weekly could lower the spread of the virus by about 60 percent , they posit .
So , Mina suggests , we shouldn ’ t just be asking what level of sensitivity a test has , but rather , what it ’ s sensitive to .
PCR tests are great at finding traces of the coronavirus but , he says , “ it ’ s going to have a 0 percent sensitivity to detect @ @ @ @ @ @ @ is to start finding elephants — or people who are most infectious — we should look for new testing options , he argues .
The FDA ’ s job is to help keep us safe , but it might lack a pandemic public health protocol One of the FDA ’ s essential responsibilities is to make sure dangerous medications , ineffective vaccines , or misleading diagnostic tests don ’ t make it to US consumers .
So it applies rigorous standards to make sure new products are reliable before they are allowed on @ @ @ @ @ @ @ applied this same rubric when it has evaluated new tests for the coronavirus this year .
“ Tests are still being considered first and foremost as diagnostic tools , ” Mina says .
This is evident in how the FDA has required antigen tests to perform at PCR-levels in detecting traces of the virus in people ’ s systems , he notes .
For example , a new test might need to detect the virus in 80 or 90 percent of emergency room patients who ’ ve received a positive PCR test .
@ @ @ @ @ @ @ see a test that catches half or a third of the positive cases a PCR test does , it makes sense for the FDA to worry about a huge number of Covid-19-positive people thinking they are negative .
And Mina says he gets that .
“ If I ’ m a doctor , which I am , and I have a patient in front of me , I would want the absolute best and most sensitive molecular test to make sure I don ’ t miss something , ” he says .
But @ @ @ @ @ @ @ For public health , it ’ s totally different .
It requires a really different type of thinking.
” One that targets minimizing spread of the virus among people .
“ Unfortunately , the FDA just doesn ’ t have that , ” he says .
“ They don ’ t even have a lens with which to think about it.
” And so , he says , they ’ re still evaluating at-home antigen tests as individual medical diagnostic tools rather than “ as a virus control tool at the population level.
@ @ @ @ @ @ @ antigen-based tests , including ones from Quidel ( in May ) , BD Veritor ( in July ) , LuminaDX ( in August ) , and the new one from Abbott .
To meet the FDA ’ s current sensitivity standards , however , the first three of these use proprietary machines to read results .
( Some of these machines are now being allocated by the Centers for Medicare & Medicaid Services to nursing homes around the country . )
But an over-the-counter antigen test , the sort that Mina and others @ @ @ @ @ @ @ t be authorized under the current standards .
This gets at the essential tension between the FDA ’ s individual-based medical diagnostic framework and the broader public health needs of the pandemic .
And , says Tsai , “ We really need to shift gears.
” Beyond the sensitivity question , the FDA and others also have hesitations about these sorts of tests being done outside of the health care setting .
Current Covid-19 tests require a health care professional to order them and provide the results , allowing for them to give @ @ @ @ @ @ @ taking these tests on their own at home or before entering a business , a nurse won ’ t be on hand , for example , to advise them to isolate if necessary or take other steps to prevent spread .
“ Due to the lack of healthcare professional supervision , FDA believes it is important for over-the-counter non-lab diagnostic tests to have a low rate of false negative results , ” Emma Spaulding , a spokesperson for the FDA wrote to Vox in an email .
“ For example , an individual @ @ @ @ @ @ @ OTC diagnostic test may be less likely to quarantine despite symptoms , putting others in the community at risk , ” This is one reason they are recommending such tests catch 90 percent of the PCR-positive cases , she says .
They would lower this to 80 percent if the tests required a prescription and were done under the supervision of a health care worker ( such as via telemedicine ) .
Others worry about individual compliance .
Rebecca Lee Smith , an epidemiologist at the University of Illinois , notes that this @ @ @ @ @ @ @ readily adopted by people who are already putting in the most effort to avoid catching and spreading Covid-19 , such as those regularly wearing masks and practicing physical distancing .
“ But the people who aren ’ t concerned about the virus may not choose to do at-home testing — they ’ re also the people who are not taking the precautions .
So the same people we would absolutely want to be checking for the virus , then , would be the people less likely to do it at home.
” She @ @ @ @ @ @ @ used to clear people for work , school , or other activities .
If someone needed to produce a negative test result , they could theoretically get someone else to take the test for them but still gain entry to , say , their college classes for the day .
That was a point of discussion at her university , where they eventually opted for supervised ( rather than collected-at-home ) saliva-based PCR testing .
“ We decided that it was more important that we know , for sure , that the person @ @ @ @ @ @ @ person giving the sample , ” she says .
Administering these tests out in the community as a way to enter a workplace or a restaurant , for example , could also help alleviate this issue — as well as the concern about those with higher chances of contracting the virus not taking the test .
The newly approved Abbott test , BinaxNOW , is a step toward more accessible antigen testing .
It doesn ’ t require a machine to read the results — and still , according to data presented to @ @ @ @ @ @ @ specificity level compared with PCR tests .
It is also $ 5 for one test , and the company says they will be able to ship 50 million of them a month this fall .
The downside is it is only available with a prescription , and it needs to be given by a health care professional or other trained individual ( such as a pharmacist or workplace health specialist ) .
The test requires a nasal swab and a small amount of specialized chemicals known as reagents .
And it is only @ @ @ @ @ @ @ Covid-19 symptoms within the past week , making it inapplicable for broader population-wide screening .
With an over-the-counter test , we might also lose a lot of important public health disease surveillance data .
If people are testing positive at home — or even in a public setting — and not following up with a health care worker or public health department , their case might not get counted or their contacts traced .
“ You would need to have a link back to public health , ” Smith says .
They would @ @ @ @ @ @ @ test that was performed so they could properly interpret the results .
This is where our existing PCR testing capacity could run backup .
Smith explains that a positive antigen test result could be a trigger to get a PCR test to confirm the infection .
It could also possibly reduce the number of PCR tests that are run , potentially speeding up delivery of those results as well .
“ In a perfect world , ” Smith says , “ we would have this cheap , at-home test that anybody could take @ @ @ @ @ @ @ that would give them a quick result .
If there is a reason — if they have symptoms , if they ’ ve been exposed , or the at-home test comes back positive — then they report for PCR.
” Tsai agrees PCR tests would still be important .
“ It ’ s really thinking about how we use the pros and cons of all the different tests in a more comprehensive strategy , ” he says .
“ Let ’ s put these pieces together.
” How could at-home antigen tests get @ @ @ @ @ @ @ a regulatory stalemate in the FDA ’ s current authorization system , experts are spitballing alternative routes to getting these tests to the public .
First and foremost , says Mina , government involvement in authorizing new tests is essential to make sure that those that do reach the market work in the way they are supposed to .
One route for this , he proposes , is a new standard by which the FDA could authorize tests , setting a different benchmark for test sensitivity at levels of the virus that are @ @ @ @ @ @ @ at very low detectable levels .
In other words , he notes , the FDA could adjust their language from looking at sensitivity to the virus broadly to “ sensitivity during peak infection.
” “ I think Americans , including policymakers , are having a hard time coming to terms with the idea that there ’ s actually something bad happening to us ” The FDA could also reframe the way it characterizes these tests , he says .
Instead of being evaluated as an individual diagnostic test , he says , “ @ @ @ @ @ @ @ transmission-detecting test ... [ or ] a public health diagnostic test , where the real reason of doing that diagnostic test is one of public health.
” Another option would be to designate these tests as surveillance tools rather than diagnostic tests .
Under that category , they fall outside the FDA ’ s purview and would more likely be overseen by the CDC and local health departments .
This plan has a big hitch , though .
Surveillance test results are aggregated and are not shared back with the individual taking the @ @ @ @ @ @ @ other hand , are those which have results given back to the individual so that they might take a specific action .
The latter is , of course , the goal here ( to let people know , for example , if they need to start self-isolating ) .
“ It ’ s this awful catch-22 that could easily be changed if there was a will , ” Mina says .
“ There just doesn ’ t seem to be much of a will.
” Or a regulatory framework for thinking about things @ @ @ @ @ @ @ a pandemic , he says .
The FDA has recently conceded that they would consider authorizing a less sensitive test if it were part of a high-frequency testing plan , with each person being tested multiple times ( which they call “ serial testing ” ) , Spaulding says .
This , to Mina and others , seems like a step in the right direction , and he is hoping the FDA will provide more detailed guidance on what this would look like in practice .
But the FDA also notes that it @ @ @ @ @ @ @ of serial testing to “ include the capacity to manufacture a sufficient supply of tests with which to conduct multiple tests per person , ” Spaulding says .
Mina suggests that this is an arbitrary ask .
For other authorized tests , like those using PCR or machine-based antigen detection , the agency has not required makers to show manufacturing capacity — or even the supply chain to turn results around in a certain amount of time ( which is a key aspect to slowing transmission of Covid-19 ) .
“ They ’ @ @ @ @ @ @ @ take a year to return results , but that ’ s a 100 percent useless test , ” Mina says .
Mina also worries that as some of these companies with at-home antigen tests wait for the government to greenlight them , they will decide to make them more complex to meet the current ( PCR-based ) requirements for diagnostic viral detection .
He calls this going from the sort of “ instant coffee model ” of testing ( where anyone can take a test , cheaply , pretty much anywhere ) to @ @ @ @ @ @ @ you need access to a specialized machine to get a result ) .
And slowdowns in rolling out these machine-based antigen tests are already happening .
Both BD and Quidel , two companies making rapid antigen tests , are now facing supply chain issues as they try to fulfill orders for their machines and tests , the Wall Street Journal reported .
Tsai notes that public health officials in Florida have been advised to use the Quidel antigen tests only for symptomatic , older adults .
Which , he says , makes sense @ @ @ @ @ @ @ from the virus , but “ in some ways also defeats the purpose of the frequent testing strategy.
” Mina has been challenging those who are still on the fence about rapid , at-home antigen testing to say whether , in hindsight , it would have been good to have five months ago .
“ Almost all of them say , ‘ yes , that would have been great.
’ Compared to what has happened , of course it would have been great.
” Now , he says , “ we ’ re @ @ @ @ @ @ @ we ’ re hitting up against September and October , when coronaviruses can start spreading like crazy .
We have to cut our losses and say , ‘ okay , we didn ’ t do it five months ago , but we can do it today.
’ ” Like the old tree-planting aphorism : The best time to plant a tree may have been 20 years ago , but the second-best time is now .
“ We could potentially save ourselves from ourselves in the fall .
But I don ’ t know @ @ @ @ @ @ @ , frankly , ” he says .
Part of that reason , he notes , has to do with our general national mindset .
“ I think Americans , including policymakers , are having a hard time coming to terms with the idea that there ’ s actually something bad happening to us.
” Just adding this new type of testing on its own , however , won ’ t be enough to get us out of the pandemic .
“ We can ’ t test our way out of it , ” @ @ @ @ @ @ @ masks , we need distancing.
” But , she says , many presymptomatic and asymptomatic cases are not being detected with our current testing strategy .
“ And those people are able to spread the infection further without knowing it .
If we can ’ t identify these cases , we are never going to get out of this.
” Katherine Harmon Courage is a freelance science journalist and author of Cultured and Octopus !
Find her on Twitter at @ KHCourage .
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To get the US pandemic under control, a growing number of health and medical experts are making a clarion call for an additional testing approach to Covid-19.
What we need, they argue, are at-home rapid tests that look for antigens, proteins the live virus makes. These kits would allow anyone to test themselves for the coronavirus any time (and anywhere) for between $1 and $5, and get results in about 15 minutes. No doctors, labs, expensive machines, or special chemicals required.
“I see these [antigen] tests as a solution that’s literally sitting in front of us,” says Michael Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health, who has led an effort to get these rapid tests authorized by the Food and Drug Administration. “We could be getting massive outbreaks down to nothing. ... It’s a no-brainer to me.”
Back in April, Deborah Birx, the White House coronavirus response coordinator, actually called for just this sort of solution in an interview on Meet the Press. “We have to have a breakthrough innovation in testing,” she said. “We have to be able to detect antigen.”
Several small companies have been developing these simple tests, and the conglomerate 3M is working with MIT on another one. (The new BinaxNOW test from Abbott, authorized August 26, is different — it requires a health professional to administer it, and the patient must have symptoms to get a prescription.)
And some of these at-home tests are ready to go. But they have been sitting on the shelf, unused, for months. Why?
The holdup is that rapid, over-the-counter antigen tests are not nearly as sensitive to the coronavirus as the molecular PCR (polymerase chain reaction) tests currently used for most Covid-19 testing. In fact, by PCR standards, some at-home antigen tests might catch only half or a third of people who test positive on a PCR test.
But that’s because they’re looking for different things in different ways. A PCR test, designed to diagnose an individual with infection, can catch very low levels of viral material before or after a person spreads the virus. An over-the-counter antigen test, meanwhile, relies on high levels of the virus to be able to detect it. These high levels, though, also happen to coincide with when a person is most likely to transmit the virus to others.
“The antigen test is maximally sensitive at the same time that you are maximally infectious,” says David Paltiel, a professor of public health and health policy at the Yale School of Public Health. “The antigen test is picking up the infections I want. Because I don’t care about infections, I care about infectiousness.”
Since at-home antigen tests would be fast and cheap, they could allow people to test themselves regularly. Currently, PCR testing is relatively expensive (about $100) and often experiences processing delays that hamstring efforts to stop transmission.
PCR tests’ sensitivity, however, is the current benchmark by which the FDA judges new tests for emergency authorization.
This pre-pandemic framework, Mina and others argue, is a problem as we look for the most effective tools to fight the coronavirus right now. So they are calling for a new way to evaluate these tests, one based in public health terms rather than individual diagnostic ones — in other words, widely accessible tests that are well tuned to find those who are most likely to spread the virus.
Let’s take a look at how and why this potential solution has gotten sidelined in the pandemic battle — and what might be done to get these tests off companies’ shelves and out to the public.
A test to find infectiousness, not infection
To understand the stalemate around antigen tests, it’s helpful to first understand what they are, how they differ from classic PCR tests, and the trajectory of coronavirus infections.
First: An antigen test looks for a particular protein from a live virus. (Not to be confused with an antibody test, which finds immune cells your body has made after mounting a defense against the virus.) These tests need a lot of viral material to generate a positive result.
Second: A PCR test looks for the virus’s genetic material — its RNA — making copies of itself until it reaches a detectable level. As a result, it has a fairly low (although not perfect) false-negative rate, or the proportion of time it would tell someone who has the virus that they don’t.
Finally: One of this new coronavirus’s superpowers is its ability to spread from people before they start to experience symptoms. In fact, people tend to carry the most live virus the day or so before they begin feeling sick, and the amount tends to quickly trail off in the several days after symptom onset.
Related How people without symptoms can still spread the coronavirus
So proponents of at-home antigen testing say that PCR tests, while useful in determining whether an individual is infected with Covid-19, are actually a poor tool in finding people who are most likely to spread the virus. That’s because PCR tests are so sensitive, they are excellent at picking up traces of the virus even after someone has beat it back and is no longer infectious.
Thomas Tsai, a health policy expert at the Harvard T.H. Chan School of Public health, compares the two types of testing this way: PCR tests are reactive tests, usually used for people who either have symptoms, a close contact with the virus, or other reason to think they are likely to have caught it. Rapid, widespread antigen tests are proactive tests, designed to find cases before they spread the virus more widely.
And as the Center for Evidence-Based Medicine noted earlier this month, “while an infectious stage may last a week or so because inactivated RNA degrades slowly over time, it may still be detected many weeks after infectiousness has dissipated.”
To look a little bit deeper at how this works, an August 7 preprint report which hasn’t been peer reviewed proposes that people with 10,000 copies of the virus detected in their airways are unlikely to spread the virus to someone else, even with sustained contact (according to their models, it would happen about 0.002 percent of the time). Once that viral load climbs to 10 million copies (which happens quickly, potentially in about a day), they have about a 40 percent chance of transmitting it to a close contact — and about 80 percent chance at 100 million viral copies (it’s worth noting that when they first reach this level they still might not have any symptoms).
By the time someone has had Covid-19 symptoms for several days (which might currently be about the time they receive results from a PCR test), however, the amount of virus in their system has likely waned to the point of actually being less transmissible. As the authors of the study note, “transmission after the first week of infection is quite rare.”
At that point, says Mina, it’s more likely that “they just have residual [virus] RNA hanging about.” So although many of these people would get a positive PCR test — and a negative at-home antigen test — they are much less likely to transmit the virus than someone who feels fine now but will develop symptoms in a day or two.
“The PCR is being fooled all the time,” Paltiel says. “The PCR is just picking up strands of viral junk.” If your goal is to slow an outbreak, he notes, this sort of data is not actually that useful. “Outbreak control is all about figuring out who’s actually spreading this stuff.”
This could also help explain why so many people continue to get positive PCR test results weeks after getting over most of their symptoms. One small JAMA study, for example, found that one in six former Covid-19 patients with no symptoms tested positive for the virus via PCR test four to 24 days after being discharged from the hospital. As an author of a commentary about that paper noted about these long-tail positive test results, “the clinical significance and infectivity are minimal. These PCR tests likely are responding to noninfective RNA fragments and do not represent detection of viable virus.”
Antigen tests, however, need a much higher level of the virus to register a positive result because they don’t rely on multiplying their target.
This, experts argue, make them well matched for finding people with Covid-19 at precisely their most infectious points rather than potentially long after symptoms have arrived and infectiousness has faded, as is more likely now with the long delays in PCR results and contact tracing. As Paltiel describes it, the concept is pretty simple: “The more viruses around your airway, the more likely you are to be a risk to others.”
According to an analysis from the June preprint (on which Mina was a co-author), this crucial time period is precisely where the antigen test is most sensitive: detecting viral load at around 10,000 copies, which is just before someone’s infectiousness skyrockets. PCR tests, on the other hand, can pick up about 1,000 copies of the virus, which gives them about a day’s head start at finding the virus. Although with a lag of more than a day in returning results, that benefit is lost.
To put it in other terms, these tests could be “superspreading detectors,” Mina says, locating many of those who would otherwise go on to unknowingly infect many other people before they know they have the virus.
“Their whole goal is to capture the 90 percent of people who might be transmitting the virus,” Mina says. So if they were to be evaluated in this population — those with high levels of the virus — he says, the sensitivity for these tests would soar from 30 or 50 percent (as measured against PCR) up to 95 percent. (They also have very low false-positive rates, in which they would tell someone they had the virus when they actually didn’t.)
Another selling point to antigen tests, proponents argue, is that they would give people their results much faster than PCR tests. Since delays of more than a day or so in getting PCR results back make containment and tracing much less effective, being able to have results back in 15 minutes or so would be a vast improvement.
“Of all the variables that we control, the frequency of screening is the most important”
Because these tests would be fast and affordable, people could also test frequently, which could help overcome worry about the tests being less sensitive than PCR — especially in the very small window early in an infection when a PCR test might catch the virus but an antigen test wouldn’t.
And such frequent testing would be far superior to the still relatively rare PCR testing that we’re currently doing, Paltiel says. “Of all the variables that we control, the frequency of screening is the most important,” he says. Even if the antigen-based test only caught half of all cases (regardless of infectiousness level), he says, if it’s “between a test that is missing 50 percent [but rapid and easy] and a test that is getting everyone that is so expensive or so cumbersome or has such a long turnaround time that it takes a week, I’ll take what’s behind door No. 1.”
In the June preprint study, the researchers found the sensitivity of a test made little difference in the rate at which it could bring viral transmission down. For example, running either of these tests, PCR or at-home antigen testing, on a population weekly could lower the spread of the virus by about 60 percent, they posit.
We can bring this pandemic under control within weeks
Without shutting down the economy
With technology we have now
Cheaply
But we won't
Because of @US_FDA backward thinking about tests
Watch @j_g_allen video. Then, don't get mad. Let's act.#dailyquicktest https://t.co/dWYCE8JpNA — Ashish K. Jha (@ashishkjha) August 17, 2020
So, Mina suggests, we shouldn’t just be asking what level of sensitivity a test has, but rather, what it’s sensitive to. PCR tests are great at finding traces of the coronavirus but, he says, “it’s going to have a 0 percent sensitivity to detect elephants.” And if what we want is to start finding elephants — or people who are most infectious — we should look for new testing options, he argues.
The FDA’s job is to help keep us safe, but it might lack a pandemic public health protocol
One of the FDA’s essential responsibilities is to make sure dangerous medications, ineffective vaccines, or misleading diagnostic tests don’t make it to US consumers. So it applies rigorous standards to make sure new products are reliable before they are allowed on the market.
And the FDA has applied this same rubric when it has evaluated new tests for the coronavirus this year.
“Tests are still being considered first and foremost as diagnostic tools,” Mina says. This is evident in how the FDA has required antigen tests to perform at PCR-levels in detecting traces of the virus in people’s systems, he notes. For example, a new test might need to detect the virus in 80 or 90 percent of emergency room patients who’ve received a positive PCR test.
So when you compare the numbers and see a test that catches half or a third of the positive cases a PCR test does, it makes sense for the FDA to worry about a huge number of Covid-19-positive people thinking they are negative.
And Mina says he gets that. “If I’m a doctor, which I am, and I have a patient in front of me, I would want the absolute best and most sensitive molecular test to make sure I don’t miss something,” he says.
But he is also an epidemiologist. “For public health, it’s totally different. It requires a really different type of thinking.” One that targets minimizing spread of the virus among people.
“Unfortunately, the FDA just doesn’t have that,” he says. “They don’t even have a lens with which to think about it.”
And so, he says, they’re still evaluating at-home antigen tests as individual medical diagnostic tools rather than “as a virus control tool at the population level.”
The FDA has already authorized four antigen-based tests, including ones from Quidel (in May), BD Veritor (in July), LuminaDX (in August), and the new one from Abbott. To meet the FDA’s current sensitivity standards, however, the first three of these use proprietary machines to read results. (Some of these machines are now being allocated by the Centers for Medicare & Medicaid Services to nursing homes around the country.)
But an over-the-counter antigen test, the sort that Mina and others are advocating for, simply can’t be authorized under the current standards.
This gets at the essential tension between the FDA’s individual-based medical diagnostic framework and the broader public health needs of the pandemic. And, says Tsai, “We really need to shift gears.”
Concerns remain about at-home antigen testing
Beyond the sensitivity question, the FDA and others also have hesitations about these sorts of tests being done outside of the health care setting.
Current Covid-19 tests require a health care professional to order them and provide the results, allowing for them to give patients medical advice. If people are taking these tests on their own at home or before entering a business, a nurse won’t be on hand, for example, to advise them to isolate if necessary or take other steps to prevent spread.
“Due to the lack of healthcare professional supervision, FDA believes it is important for over-the-counter non-lab diagnostic tests to have a low rate of false negative results,” Emma Spaulding, a spokesperson for the FDA wrote to Vox in an email. “For example, an individual with a false negative result from an OTC diagnostic test may be less likely to quarantine despite symptoms, putting others in the community at risk,”
This is one reason they are recommending such tests catch 90 percent of the PCR-positive cases, she says. They would lower this to 80 percent if the tests required a prescription and were done under the supervision of a health care worker (such as via telemedicine).
Others worry about individual compliance. Rebecca Lee Smith, an epidemiologist at the University of Illinois, notes that this sort of testing would probably be most readily adopted by people who are already putting in the most effort to avoid catching and spreading Covid-19, such as those regularly wearing masks and practicing physical distancing.
“But the people who aren’t concerned about the virus may not choose to do at-home testing — they’re also the people who are not taking the precautions. So the same people we would absolutely want to be checking for the virus, then, would be the people less likely to do it at home.”
She also has concerns about at-home tests being used to clear people for work, school, or other activities. If someone needed to produce a negative test result, they could theoretically get someone else to take the test for them but still gain entry to, say, their college classes for the day. That was a point of discussion at her university, where they eventually opted for supervised (rather than collected-at-home) saliva-based PCR testing. “We decided that it was more important that we know, for sure, that the person who checked in for testing is the person giving the sample,” she says.
Administering these tests out in the community as a way to enter a workplace or a restaurant, for example, could also help alleviate this issue — as well as the concern about those with higher chances of contracting the virus not taking the test.
The newly approved Abbott test, BinaxNOW, is a step toward more accessible antigen testing. It doesn’t require a machine to read the results — and still, according to data presented to the FDA, has a 97 percent specificity level compared with PCR tests. It is also $5 for one test, and the company says they will be able to ship 50 million of them a month this fall.
The downside is it is only available with a prescription, and it needs to be given by a health care professional or other trained individual (such as a pharmacist or workplace health specialist). The test requires a nasal swab and a small amount of specialized chemicals known as reagents. And it is only to be used for people who developed Covid-19 symptoms within the past week, making it inapplicable for broader population-wide screening.
With an over-the-counter test, we might also lose a lot of important public health disease surveillance data. If people are testing positive at home — or even in a public setting — and not following up with a health care worker or public health department, their case might not get counted or their contacts traced. “You would need to have a link back to public health,” Smith says. They would also want to get information on the test that was performed so they could properly interpret the results.
This is where our existing PCR testing capacity could run backup. Smith explains that a positive antigen test result could be a trigger to get a PCR test to confirm the infection. It could also possibly reduce the number of PCR tests that are run, potentially speeding up delivery of those results as well.
“In a perfect world,” Smith says, “we would have this cheap, at-home test that anybody could take, as frequently as they want, that would give them a quick result. If there is a reason — if they have symptoms, if they’ve been exposed, or the at-home test comes back positive — then they report for PCR.”
Tsai agrees PCR tests would still be important. “It’s really thinking about how we use the pros and cons of all the different tests in a more comprehensive strategy,” he says. “Let’s put these pieces together.”
How could at-home antigen tests get authorized?
With over-the-counter antigen tests at a regulatory stalemate in the FDA’s current authorization system, experts are spitballing alternative routes to getting these tests to the public.
First and foremost, says Mina, government involvement in authorizing new tests is essential to make sure that those that do reach the market work in the way they are supposed to.
One route for this, he proposes, is a new standard by which the FDA could authorize tests, setting a different benchmark for test sensitivity at levels of the virus that are most likely to be transmissible rather than at very low detectable levels. In other words, he notes, the FDA could adjust their language from looking at sensitivity to the virus broadly to “sensitivity during peak infection.”
“I think Americans, including policymakers, are having a hard time coming to terms with the idea that there’s actually something bad happening to us”
The FDA could also reframe the way it characterizes these tests, he says. Instead of being evaluated as an individual diagnostic test, he says, “it would essentially be indicated as a transmission-detecting test ... [or] a public health diagnostic test, where the real reason of doing that diagnostic test is one of public health.”
Another option would be to designate these tests as surveillance tools rather than diagnostic tests. Under that category, they fall outside the FDA’s purview and would more likely be overseen by the CDC and local health departments.
This plan has a big hitch, though. Surveillance test results are aggregated and are not shared back with the individual taking the test. Diagnostic tests, on the other hand, are those which have results given back to the individual so that they might take a specific action. The latter is, of course, the goal here (to let people know, for example, if they need to start self-isolating).
“It’s this awful catch-22 that could easily be changed if there was a will,” Mina says. “There just doesn’t seem to be much of a will.” Or a regulatory framework for thinking about things differently — even in the midst of a pandemic, he says.
The FDA has recently conceded that they would consider authorizing a less sensitive test if it were part of a high-frequency testing plan, with each person being tested multiple times (which they call “serial testing”), Spaulding says.
This, to Mina and others, seems like a step in the right direction, and he is hoping the FDA will provide more detailed guidance on what this would look like in practice.
But the FDA also notes that it would require an application for this sort of serial testing to “include the capacity to manufacture a sufficient supply of tests with which to conduct multiple tests per person,” Spaulding says.
Mina suggests that this is an arbitrary ask. For other authorized tests, like those using PCR or machine-based antigen detection, the agency has not required makers to show manufacturing capacity — or even the supply chain to turn results around in a certain amount of time (which is a key aspect to slowing transmission of Covid-19). “They’re perfectly fine approving tests that might take a year to return results, but that’s a 100 percent useless test,” Mina says.
Mina also worries that as some of these companies with at-home antigen tests wait for the government to greenlight them, they will decide to make them more complex to meet the current (PCR-based) requirements for diagnostic viral detection.
He calls this going from the sort of “instant coffee model” of testing (where anyone can take a test, cheaply, pretty much anywhere) to the “Nespresso model” (where you need access to a specialized machine to get a result).
And slowdowns in rolling out these machine-based antigen tests are already happening. Both BD and Quidel, two companies making rapid antigen tests, are now facing supply chain issues as they try to fulfill orders for their machines and tests, the Wall Street Journal reported.
Tsai notes that public health officials in Florida have been advised to use the Quidel antigen tests only for symptomatic, older adults. Which, he says, makes sense in targeting those most at-risk for complications from the virus, but “in some ways also defeats the purpose of the frequent testing strategy.”
Mina has been challenging those who are still on the fence about rapid, at-home antigen testing to say whether, in hindsight, it would have been good to have five months ago.
“Almost all of them say, ‘yes, that would have been great.’ Compared to what has happened, of course it would have been great.” Now, he says, “we’re in an almost worse spot today, we’re hitting up against September and October, when coronaviruses can start spreading like crazy. We have to cut our losses and say, ‘okay, we didn’t do it five months ago, but we can do it today.’”
Like the old tree-planting aphorism: The best time to plant a tree may have been 20 years ago, but the second-best time is now. “We could potentially save ourselves from ourselves in the fall. But I don’t know if it’s going to happen, frankly,” he says.
Part of that reason, he notes, has to do with our general national mindset. “I think Americans, including policymakers, are having a hard time coming to terms with the idea that there’s actually something bad happening to us.”
Just adding this new type of testing on its own, however, won’t be enough to get us out of the pandemic. “We can’t test our way out of it,” Smith says. “We also need masks, we need distancing.”
But, she says, many presymptomatic and asymptomatic cases are not being detected with our current testing strategy. “And those people are able to spread the infection further without knowing it. If we can’t identify these cases, we are never going to get out of this.”
Katherine Harmon Courage is a freelance science journalist and author of Cultured and Octopus! Find her on Twitter at @KHCourage.
New goal: 25,000
In the spring, we launched a program asking readers for financial contributions to help keep Vox free for everyone, and last week, we set a goal of reaching 20,000 contributors. Well, you helped us blow past that. Today, we are extending that goal to 25,000. Millions turn to Vox each month to understand an increasingly chaotic world — from what is happening with the USPS to the coronavirus crisis to what is, quite possibly, the most consequential presidential election of our lifetimes. Even when the economy and the news advertising market recovers, your support will be a critical part of sustaining our resource-intensive work — and helping everyone make sense of an increasingly chaotic world. Contribute today from as little as $3.


The great rebuild

The Covid-19 pandemic is a tragedy , a massive policy failure , and an existential threat to the livelihood and health of millions of Americans — with the pain disproportionality falling on Black Americans .
With more than 5 million cases worldwide , more than 175,000 Americans dead , more than 16 million US jobs eliminated , and schools and businesses shuttered , half measures won ’ t cut it .
It didn ’ t have to be this way .
However , there is still much we can do to recover — and not just recover , but rebuild @ @ @ @ @ @ @ thinkers , economists , and policymakers , The Great Rebuild imagines how we could marshal the power of the federal government and the potential of its citizens to fight back against the catastrophic effects of Covid-19 , and in the process create a system steeped in fairness , inclusion , and sustainability .
The Great Rebuild is made possible thanks to support from Omidyar Network , a social impact venture that works to reimagine critical systems and the ideas that govern them , and to build more inclusive and equitable societies .
All @ @ @ @ @ @ @ produced by our journalists .
How to decarbonize America — and create 25 million jobs The US has the technology to decarbonize by 2035 .
Here ’ s a plan to do it .
What it would take to end child poverty in America Rep. Barbara Lee on why rebuilding the economy should mean investing in our kids .
What would Keynes do ?
What the 20th century ’ s most influential economist can teach us about rebuilding the US economy .
The failed dream of the American small business Small businesses were @ @ @ @ @ @ @ and systemic forces left many fighting for survival .
Then came the pandemic .

The Covid-19 pandemic is a tragedy, a massive policy failure, and an existential threat to the livelihood and health of millions of Americans — with the pain disproportionality falling on Black Americans.
A problem this big demands a bold solution.
With more than 30 million cases worldwide, more than 200,000 Americans dead, millions of US jobs eliminated, and schools and businesses shuttered, half measures won’t cut it. It didn’t have to be this way. However, there is still much we can do to recover — and not just recover, but rebuild.
Tapping the voices of prominent American thinkers, economists, and policymakers, The Great Rebuild imagines how we could marshal the power of the federal government and the potential of its citizens to fight back against the catastrophic effects of Covid-19, and in the process create a system steeped in fairness, inclusion, and sustainability.
The Great Rebuild is made possible thanks to support from Omidyar Network, a social impact venture that works to reimagine critical systems and the ideas that govern them, and to build more inclusive and equitable societies. All Great Rebuild coverage is editorially independent and produced by our journalists.
A blueprint exists for a more inclusive, successful nation that invests in the well-being of its citizens. We only have to look to the past.
by Zachary D. Carter
The problem with our social safety net is clear. The solution is, too.
by Emily Stewart
We have more than enough work to go around for the next generation if we address one of our nation’s biggest problems: infrastructure.
by Andrew Yang
It’s time to ask why we continue to spend millions of taxpayer dollars on police misconduct lawsuits and billions more on policing that yields poor outcomes.
by Sean Collins
A massive boom in new construction would create countless jobs and help finally end the legacy of racist housing policies.
by Matthew Yglesias
We must bail out the industry that allows millions of parents to work.
by Anna North
The former presidential candidate discusses universal basic income, artificial intelligence, and his next job in politics.
by Ezra Klein
The US has the technology to decarbonize by 2035. Here’s a plan to do it.
By Ezra Klein
Rep. Barbara Lee on why rebuilding the economy should mean investing in our kids.
By Ezra Klein
What the 20th century’s most influential economist can teach us about rebuilding the US economy.
By Ezra Klein
Small businesses were once pillars of communities, but economic and systemic forces left many fighting for survival. Then came the pandemic.
By Laura Entis
Party of One is a collaborative creative studio founded by Melissa Deckert and Nicole Licht, based in Brooklyn, New York. Through combined experience in fine arts and traditional design, Party of One creates compelling visuals with an emphasis on unique and often handcrafted prop design, styling, and sets.


vox--2020-08-28--Trump, Biden, and the war over American masculinity

When voters decide between President Trump and former Vice President Joe Biden this November , they ’ ll be choosing between two parties , two histories , and two very different visions of America .
They ’ ll also be deciding between two versions of masculinity .
Trump has made a certain kind of stereotypical manliness core to his campaign ever since 2016 .
He bragged about his penis size during one debate , physically invaded Hillary Clinton ’ s space during another , and repeatedly insulted his opponents ’ “ toughness , ” “ energy , ” and “ @ @ @ @ @ @ @ presidency and has defined his response to the Covid-19 pandemic , during which he has claimed the virus will go away on its own , called on Americans to be “ warriors ” by reopening the economy , and routinely refused to wear a mask .
In his acceptance speech at the Republican National Convention on Thursday night — delivered before a largely mask-free crowd — he again used the language of war , boasting that “ we will crush the virus ” and claiming that his opponent ’ s plan on the @ @ @ @ @ @ @ the virus , but rather a surrender.
” He also , yet again , demanded that states open their economies despite hundreds of daily deaths , saying , “ they have to be open , they have to get back to work.
” Trump has also long used the public health crisis as an opportunity to ramp up his xenophobic rhetoric , by using a racist name for the virus — something he did again in his convention speech .
These bigoted and aggressive comments are part of his larger performance of masculinity @ @ @ @ @ @ @ conflated his being a man with being a racist , ” William Ming Liu , a professor of counseling , higher education , and special education at the University of Maryland , College Park , who studies masculinity , told Vox in an email .
Biden , at least during his 2020 campaign , has set out to show voters a different kind of masculinity — and to subtly attack Trump ’ s .
In campaign appearances and at last week ’ s Democratic National Convention , he ’ s cast himself as @ @ @ @ @ @ @ is “ contrasting that to Trump ’ s brute-force , reckless approach , ” Kristin Kobes Du Mez , a history professor at Calvin University who has studied white evangelicals ’ views of masculinity , told Vox .
In his speech at the convention , for example , Biden called Trump “ a president who takes no responsibility , refuses to lead , blames others , cozies up to dictators , and fans the flames of hate and division.
” And he offered voters , instead , his vision of America : “ @ @ @ @ @ @ @ selfless , and humble.
” “ It ’ s an America we can rebuild together , ” he promised .
As the campaign continues , and the two candidates debate each other , the conflict between their two brands of masculinity will surely be thrown into even higher relief .
And Americans — who don ’ t have the option of a female candidate this time around — will have to decide what kind of man they want in the White House in 2021 .
For Trump , masculinity has always been about @ @ @ @ @ @ @ other countries , and even attempting to display toughness in the face of a viral threat that can ’ t actually be vanquished by physical force .
It ’ s a kind of macho posturing that taps into trends in the American electorate that existed even before 2016 , according to Du Mez .
Starting in the early 2000s , a “ militant , testosterone-driven vision of Christian manhood ” began to take hold in evangelical circles , she said — one that “ condoned violence in the pursuit of righteousness ” as @ @ @ @ @ @ @ “ It was a real kind of backlash against feminism , against the emasculation of American men , ” Du Mez said .
Trump ’ s 2016 campaign played right into these ideas .
Evangelical voters “ talk about him as their ultimate fighting champion , as their strongman , ” Du Mez said .
Even comments like those caught on the Access Hollywood tape , in which Trump bragged about his ability to grab women “ by the pussy , ” weren ’ t necessarily an issue for a voting bloc usually @ @ @ @ @ @ @ , “ a militant patriarchy is a part of family values politics , ” Du Mez said , with voters seeing Trump ’ s comments as just another example of his rugged , testosterone-fueled manliness .
Indeed , Trump won an overwhelming 77 percent of white evangelical votes in 2016 , with just 16 percent going to Clinton .
And it ’ s not just evangelicals .
Over time , the embrace of militant masculinity has “ created bonds across religious differences ” between Christian and secular conservatives , Du Mez said .
@ @ @ @ @ @ @ a kind of pre-feminist or feminist-backlash retrograde masculinity as the antidote to all that ails the country today.
” Trump ’ s approach may also appeal to a wide swath of white Americans who perceive masculinity — specifically white masculinity — to be under attack .
“ As communities of color demonstrate , and as communities of color become more visible and prominent , white communities regard this visibility as a threat to the traditional and expected ways of being , ” Liu said .
“ And being a white man is embedded @ @ @ @ @ @ @ The president ’ s responses to uprisings around the country in the wake of the police shootings of George Floyd , Jacob Blake , and others this year have spoken directly to those who see whiteness , and specifically white masculinity , being threatened .
In May , for example , he called protesters in Minneapolis “ thugs ” and warned , “ when the looting starts , the shooting starts ” ( his tweet was marked by Twitter as “ glorifying violence ” ) .
His “ demonstrations of authoritarianism are in @ @ @ @ @ @ @ of how white people want to treat race and racism , ” Liu said — by forcing other groups into submission .
This worldview was on display Thursday night , as Trump painted a dark picture of “ anarchists , agitators , rioters , looters , and flag-burners ” terrorizing American cities .
“ No one will be safe in Biden ’ s America , ” he proclaimed , before demanding that “ we have to give law enforcement , our police , back their power.
” “ What we can never have @ @ @ @ @ @ @ — is mob rule , ” the president continued .
Trump ’ s rhetoric and behavior around Covid-19 have also played into ideals of militant , tough-guy masculinity .
In particular , his refusal to wear a mask became part of a larger message that ignoring the risks of the coronavirus was the tough or strong thing to do .
And despite warnings from public health experts about the dangers of reopening the country too early , he said during a public appearance in May that “ the people of our country should @ @ @ @ @ @ @ “ our country has to open.
” He made that statement at a mask factory in Arizona — where he appeared without a mask .
Trump has since said that Americans should wear masks , admitting that “ they have an impact.
” But he has continued to appear in public without a mask , including at first lady Melania Trump ’ s speech in the White House Rose Garden on Tuesday night , also attended by about 70 mostly maskless audience members , and at Vice President Mike Pence ’ s speech @ @ @ @ @ @ @ greeted maskless attendees .
In his speech Thursday , Trump repeatedly described Covid-19 as an adversary his administration was bravely vanquishing .
“ In recent months , our nation , and the entire planet , has been struck by a new and powerful invisible enemy , ” Trump told his audience .
“ Like those brave Americans before us , we are meeting this challenge , ” he assured them .
“ We will defeat the virus , end the pandemic , and emerge stronger than ever before.
” For Trump , Covid-19 @ @ @ @ @ @ @ ’ s already won , or is just about to win — even though more than 180,000 people have died .
In his 2020 campaign , Biden is trying to show another path Biden has occasionally sought to present the kind of aggressive masculinity Trump favors .
In a 2018 speech referencing Trump ’ s comments on the Access Hollywood tape , for example , he said that if the two were high school classmates , “ I ’ d take him behind the gym and beat the hell out of him.
” @ @ @ @ @ @ @ for public vulgarity or insults the way Trump is , he has been accused of disrespectful and boundary-crossing behavior with women — and by one woman , of sexual assault .
Biden has denied the assault allegation and , in response to others , pledged to change his behavior in response to changing “ social norms.
” But in the past , at least according to some , he hasn ’ t always been a model of healthy masculinity .
More recently , however , as he seeks to present himself as an @ @ @ @ @ @ @ he ’ s also offered a different archetype of manliness .
For example , he ’ s “ embracing that men can have emotions , ” Du Mez said .
“ His campaign is really foregrounding his own loss ” — the deaths of his first wife and infant daughter , and later of his son Beau — “ and then suggesting that he is better equipped to be president , perhaps especially in this moment , because he has endured such loss.
” In her speech at the Democratic National Convention , @ @ @ @ @ @ @ husband ’ s perseverance in the face of personal tragedy as evidence of his strength — and preparation for carrying the nation through the tragedy of Covid-19 .
“ The burdens we carry are heavy , and we need someone with strong shoulders , ” she said .
“ I know that if we entrust this nation to Joe , he will do for your family what he did for ours : Bring us together and make us whole , carry us forward in our time of need , keep the promise of @ @ @ @ @ @ @ her words , Biden became , not the militant , aggressive macho-man exemplified by Trump , but the powerful yet benevolent father figure America needs right now .
Biden has painted a similar picture of himself in recent months .
In his speech at the Democratic convention , he delivered a message of empathy to those who have lost loved ones in the pandemic .
“ I know how it feels to lose someone you love , ” he said .
“ I know that deep black hole that opens up in your @ @ @ @ @ @ @ being is sucked into it .
I know how mean and cruel and unfair life can be sometimes.
” Trump , too , mentioned those who have lost their lives to Covid-19 , noting that “ many Americans have sadly lost friends and cherished loved ones to this horrible disease.
” But moments later , he was referring to the virus in racist terms while bragging about his successful war against it .
And Biden didn ’ t just empathize — he also pledged to shield Americans from future threats , saying , @ @ @ @ @ @ @ will defend us from every attack .
Seen , and unseen .
Always .
Without exception .
Every time.
” And he accused Trump of failing to do the same .
“ The president keeps telling us the virus is going to disappear , ” Biden said .
“ He keeps waiting for a miracle .
Well , I have news for him , no miracle is coming.
” And , he argued , “ Our current president has failed in his most basic duty to this nation .
He failed to protect @ @ @ @ @ @ @ ” In essence , Biden didn ’ t just offer a different , more benevolent form of masculinity from Trump .
He also essentially accused Trump of failing at masculinity — of being a bad protector , an irresponsible steward of the country , and a shirker who keeps waiting for a miracle rather than doing the hard work of keeping people safe .
“ There are many different ways that masculinity is imagined , ” Du Mez says .
There ’ s Trump ’ s macho , reckless version , and then @ @ @ @ @ @ @ prioritize self-restraint , stoicism , and not whining about things.
” In his speech , Biden essentially called out Trump for failing to live up to some of those other models — for shifting blame , failing to take responsibility , and ultimately , for being weak in the face of a challenge that demands emotional as well as physical strength .
Calling Trump weak in this subtler way may be a smarter move , politically , than talking about beating him up .
The Republican primary in 2016 was a reminder that @ @ @ @ @ @ @ with tough talk , “ Trump ends up winning on that particular turf , because he has no restraint , ” Du Mez said .
And if he sticks to presenting himself as a benevolent , empathetic protector figure , Biden will certainly offer voters a clear alternative to Trump ’ s chest-beating — as well as a different model for young people of how a powerful man can behave .
“ He expresses genuine joy and laughter when he is with other people , he has a sense of humor about himself @ @ @ @ @ @ @ , he shows caring for his children , and he has empathy for others ’ joy , happiness , and pain , ” Liu said .
“ His openness to his emotions as well as his emotional connection to others informs his intellect and his decisions.
” Of course , it ’ s also telling that the 2020 election is still a contest between masculinities , with two older white men duking out over who would be a better patriarch for the country .
In a way , the real broadening of America @ @ @ @ @ @ @ to come later , when ( and if ) whoever is president next chooses to share power with others and , ultimately , passes the torch to them .
Biden has gestured toward this moment when he speaks of other leaders in America and in his campaign — most notably Sen. Kamala Harris , his running mate who once strongly challenged him on issues of systemic racism .
Harris “ is a powerful voice for this nation , ” Biden said in his speech last week .
“ Her story is the American @ @ @ @ @ @ @ has largely been written by men like Biden .
And his biggest opportunity to model new kinds of masculinity for the future may come in the ways he chooses to let others take the lead .
In the spring , we launched a program asking readers for financial contributions to help keep Vox free for everyone , and last week , we set a goal of reaching 20,000 contributors .
Well , you helped us blow past that .
Today , we are extending that goal to 25,000 .
Millions turn to Vox @ @ @ @ @ @ @ world — from what is happening with the USPS to the coronavirus crisis to what is , quite possibly , the most consequential presidential election of our lifetimes .
Even when the economy and the news advertising market recovers , your support will be a critical part of sustaining our resource-intensive work — and helping everyone make sense of an increasingly chaotic world .
Contribute today from as little as $ 3 .

When voters decide between President Donald Trump and former Vice President Joe Biden this November, they’ll be choosing between two parties, two histories, and two very different visions of America.
They’ll also be deciding between two versions of masculinity.
Trump has made a certain kind of stereotypical manliness core to his campaign ever since 2016. He bragged about his penis size during one debate, physically invaded Hillary Clinton’s space during another, and repeatedly insulted his opponents’ “toughness,” “energy,” and “stamina.”
Such behavior continued through his presidency and has defined his response to the Covid-19 pandemic, during which he has claimed the virus will go away on its own, called on Americans to be “warriors” by reopening the economy, and routinely refused to wear a mask. In his acceptance speech at the Republican National Convention on Thursday night — delivered before a largely mask-free crowd — he again used the language of war, boasting that “we will crush the virus” and claiming that his opponent’s plan on the crisis “is not a solution to the virus, but rather a surrender.” He also, yet again, demanded that states open their economies despite hundreds of daily deaths, saying, “they have to be open, they have to get back to work.”
Trump has also long used the public health crisis as an opportunity to ramp up his xenophobic rhetoric, by using a racist name for the virus — something he did again in his convention speech. These bigoted and aggressive comments are part of his larger performance of masculinity, some say. “He has conflated his being a man with being a racist,” William Ming Liu, a professor of counseling, higher education, and special education at the University of Maryland, College Park, who studies masculinity, told Vox in an email.
Biden, at least during his 2020 campaign, has set out to show voters a different kind of masculinity — and to subtly attack Trump’s. In campaign appearances and at last week’s Democratic National Convention, he’s cast himself as “a dependable serious protector” and is “contrasting that to Trump’s brute-force, reckless approach,” Kristin Kobes Du Mez, a history professor at Calvin University who has studied white evangelicals’ views of masculinity, told Vox.
In his speech at the convention, for example, Biden called Trump “a president who takes no responsibility, refuses to lead, blames others, cozies up to dictators, and fans the flames of hate and division.” And he offered voters, instead, his vision of America: “one that is generous and strong, selfless, and humble.”
“It’s an America we can rebuild together,” he promised.
As the campaign continues, and the two candidates debate each other, the conflict between their two brands of masculinity will surely be thrown into even higher relief. And Americans — who don’t have the option of a female candidate this time around — will have to decide what kind of man they want in the White House in 2021.
Trump embodies a particular form of militant masculinity
For Trump, masculinity has always been about aggression: insulting other people, threatening other countries, and even attempting to display toughness in the face of a viral threat that can’t actually be vanquished by physical force.
It’s a kind of macho posturing that taps into trends in the American electorate that existed even before 2016, according to Du Mez. Starting in the early 2000s, a “militant, testosterone-driven vision of Christian manhood” began to take hold in evangelical circles, she said — one that “condoned violence in the pursuit of righteousness” as well as vulgar language and sexism. “It was a real kind of backlash against feminism, against the emasculation of American men,” Du Mez said.
Trump’s 2016 campaign played right into these ideas. Evangelical voters “talk about him as their ultimate fighting champion, as their strongman,” Du Mez said. Even comments like those caught on the Access Hollywood tape, in which Trump bragged about his ability to grab women “by the pussy,” weren’t necessarily an issue for a voting bloc usually concerned with family values. After all, “a militant patriarchy is a part of family values politics,” Du Mez said, with voters seeing Trump’s comments as just another example of his rugged, testosterone-fueled manliness. Indeed, Trump won an overwhelming 77 percent of white evangelical votes in 2016, with just 16 percent going to Clinton.
And it’s not just evangelicals. Over time, the embrace of militant masculinity has “created bonds across religious differences” between Christian and secular conservatives, Du Mez said. “They’re similarly looking to a kind of pre-feminist or feminist-backlash retrograde masculinity as the antidote to all that ails the country today.”
Trump’s approach may also appeal to a wide swath of white Americans who perceive masculinity — specifically white masculinity — to be under attack. “As communities of color demonstrate, and as communities of color become more visible and prominent, white communities regard this visibility as a threat to the traditional and expected ways of being,” Liu said. “And being a white man is embedded within this traditional way of being.”
The president’s responses to uprisings around the country in the wake of the police shootings of George Floyd, Jacob Blake, and others this year have spoken directly to those who see whiteness, and specifically white masculinity, being threatened. In May, for example, he called protesters in Minneapolis “thugs” and warned, “when the looting starts, the shooting starts” (his tweet was marked by Twitter as “glorifying violence”). His “demonstrations of authoritarianism are in a way, a wish fulfillment, of how white people want to treat race and racism,” Liu said — by forcing other groups into submission.
This worldview was on display Thursday night, as Trump painted a dark picture of “anarchists, agitators, rioters, looters, and flag-burners” terrorizing American cities. “No one will be safe in Biden’s America,” he proclaimed, before demanding that “we have to give law enforcement, our police, back their power.”
“What we can never have in America — and must never allow — is mob rule,” the president continued.
Trump’s rhetoric and behavior around Covid-19 have also played into ideals of militant, tough-guy masculinity. In particular, his refusal to wear a mask became part of a larger message that ignoring the risks of the coronavirus was the tough or strong thing to do. And despite warnings from public health experts about the dangers of reopening the country too early, he said during a public appearance in May that “the people of our country should think of themselves as warriors” because “our country has to open.” He made that statement at a mask factory in Arizona — where he appeared without a mask.
Trump has since said Americans should wear masks, admitting that “they have an impact.” But he has continued to appear in public without a mask, including at first lady Melania Trump’s speech in the White House Rose Garden on Tuesday night, also attended by about 70 mostly maskless audience members, and at Vice President Mike Pence’s speech on Wednesday, after which he reportedly greeted maskless attendees.
In his speech Thursday, Trump repeatedly described Covid-19 as an adversary his administration was bravely vanquishing.
“In recent months, our nation, and the entire planet, has been struck by a new and powerful invisible enemy,” Trump told his audience. “Like those brave Americans before us, we are meeting this challenge,” he assured them. “We will defeat the virus, end the pandemic, and emerge stronger than ever before.”
For Trump, Covid-19 is a war, and one he’s already won, or is just about to win — even though more than 180,000 people have died.
In his 2020 campaign, Biden is trying to show another path
Biden has occasionally sought to present the kind of aggressive masculinity Trump favors. In a 2018 speech referencing Trump’s comments on the Access Hollywood tape, for example, he said that if the two were high school classmates, “I’d take him behind the gym and beat the hell out of him.”
And while Biden has never been known for public vulgarity or insults the way Trump is, he has been accused of disrespectful and boundary-crossing behavior with women — and by one woman, of sexual assault. Biden has denied the assault allegation and, in response to others, pledged to change his behavior in response to changing “social norms.” But in the past, at least according to some, he hasn’t always been a model of healthy masculinity.
More recently, however, as he seeks to present himself as an alternative to Trump in every way, he’s also offered a different archetype of manliness. For example, he’s “embracing that men can have emotions,” Du Mez said. “His campaign is really foregrounding his own loss” — the deaths of his first wife and infant daughter, and later of his son Beau — “and then suggesting that he is better equipped to be president, perhaps especially in this moment, because he has endured such loss.”
In her speech at the Democratic National Convention, for instance, Jill Biden framed her husband’s perseverance in the face of personal tragedy as evidence of his strength — and preparation for carrying the nation through the tragedy of Covid-19.
“The burdens we carry are heavy, and we need someone with strong shoulders,” she said. “I know that if we entrust this nation to Joe, he will do for your family what he did for ours: Bring us together and make us whole, carry us forward in our time of need, keep the promise of America for all of us.”
In her words, Biden became, not the militant, aggressive macho-man exemplified by Trump, but the powerful yet benevolent father figure America needs right now.
Biden has painted a similar picture of himself in recent months. In his speech at the Democratic convention, he delivered a message of empathy to those who have lost loved ones in the pandemic. “I know how it feels to lose someone you love,” he said. “I know that deep black hole that opens up in your chest. That you feel your whole being is sucked into it. I know how mean and cruel and unfair life can be sometimes.”
Trump, too, mentioned those who have lost their lives to Covid-19, noting “many Americans have sadly lost friends and cherished loved ones to this horrible disease.” But moments later, he was referring to the virus in racist terms while bragging about his successful war against it.
And Biden didn’t just empathize — he also pledged to shield Americans from future threats, saying, “I will protect America. I will defend us from every attack. Seen, and unseen. Always. Without exception. Every time.”
And he accused Trump of failing to do the same. “The president keeps telling us the virus is going to disappear,” Biden said. “He keeps waiting for a miracle. Well, I have news for him, no miracle is coming.”
And, he argued, “Our current president has failed in his most basic duty to this nation. He failed to protect us. He failed to protect America.”
In essence, Biden didn’t just offer a different, more benevolent form of masculinity from Trump. He also essentially accused Trump of failing at masculinity — of being a bad protector, an irresponsible steward of the country, and a shirker who keeps waiting for a miracle rather than doing the hard work of keeping people safe.
“There are many different ways that masculinity is imagined,” Du Mez says. There’s Trump’s macho, reckless version, and then there are “models of masculinity that prioritize self-restraint, stoicism, and not whining about things.” In his speech, Biden essentially called out Trump for failing to live up to some of those other models — for shifting blame, failing to take responsibility, and ultimately, for being weak in the face of a challenge that demands emotional as well as physical strength.
Calling Trump weak in this subtler way may be a smarter move, politically, than talking about beating him up. The Republican primary in 2016 was a reminder that when other candidates try to match Trump with tough talk, “Trump ends up winning on that particular turf, because he has no restraint,” Du Mez said.
And if he sticks to presenting himself as a benevolent, empathetic protector figure, Biden will certainly offer voters a clear alternative to Trump’s chest-beating — as well as a different model for young people of how a powerful man can behave. “He expresses genuine joy and laughter when he is with other people, he has a sense of humor about himself, he expresses warmth with his wife, he shows caring for his children, and he has empathy for others’ joy, happiness, and pain,” Liu said. “His openness to his emotions as well as his emotional connection to others informs his intellect and his decisions.”
Of course, it’s also telling that the 2020 election is still a contest between masculinities, with two older white men duking out over who would be a better patriarch for the country. In a way, the real broadening of America’s ideas of masculinity may have to come later, when (and if) whoever is president next chooses to share power with others and, ultimately, passes the torch to them.
Biden has gestured toward this moment when he speaks of other leaders in America and in his campaign — most notably Sen. Kamala Harris, his running mate who once strongly challenged him on issues of systemic racism. Harris “is a powerful voice for this nation,” Biden said in his speech last week. “Her story is the American story.”
But the story of America has largely been written by men like Biden. And his biggest opportunity to model new kinds of masculinity for the future may come in the ways he chooses to let others take the lead.
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