On Thursday, Governor Andrew Cuomo presented the addresses of five new testing sites in New York City located near communities of color—in Flatbush, Brownsville, Jamaica, the South Bronx, and at the Aqueduct Race Track near Ozone Park. The announcement came after several days of advocacy from local elected officials, who warned the high death rates in minority communities could only be stopped by ramping up testing in those communities.

The same day, Mayor Bill de Blasio at his press conference affirmed his strong support for increased testing, but said there still weren’t enough supplies, and the city needed to ration. Available tests were to be reserved for the hospitalized and critically ill, then healthcare workers and next, first line responders.

By Sunday, however, De Blasio had announced that the city would aim to launch five testing sites at Health & Hospitals facilities in East New York, Morrisania, Harlem, Jamaica, and Clifton. De Blasio said the sites would help people who live in hard-hit communities to access testing, with priority given to the most vulnerable populations. The initiative’s success, however, depends on the city being able to get more tests and personal protective equipment (PPE).

“Let’s keep finding the tests. Let’s keep finding the PPEs so we can get this up and running by the end of next week,” he said, adding that he would ask the federal government for test kits to allow for 110,000 individualized tests.

Sunday’s news was just the latest bit of ever-evolving messaging offered to the public about testing capacity within the city. With the supply of testing materials and the technologies on the market changing daily, it is unceasingly difficult to follow who can and should get a test.

Below, we’ve broken down the basics of how our testing policies have evolved, what advocates have demanded, and what might be next in store for New York when it comes to testing. Be sure to keep checking the state and city health department websites for updated policies.

The numbers

According to state testing data as of Friday, over 204,000 people have been tested so far for the virus in New York City, and about 51 percent of the tests (more than 103,000 tests) were positive. This compares to about 462,000 tests conducted statewide, with about 41 percent (almost 189,000 tests) found positive.

The backstory

Significant federal delays in the expansion of testing hampered New York State’s ability to start tracking early enough. In early March, de Blasio was still encouraging New Yorkers to be tested in the hopes of tracking where the disease was spreading. But health providers began hitting up against limits in testing supplies and lab capacity, and residents encountered escalating difficulties getting tested, along with confusing guidelines about when to get tested. Finally, the city’s Department of Health and Mental Hygiene (DOHMH) convinced the mayor to stop encouraging widespread testing and adopt a different strategy.

On March 20, the NYC DOHMH put out an advisory asking health providers not to encourage or advertise COVID-19 testing for non-hospitalized patients—and saying there was no reason to test asymptomatic or mild-to-moderately ill people, including healthcare workers and first responders.

According to the advisory, keeping patients home would protect them from each other and protect healthcare workers. Due to national shortages of personal protective equipment (PPE) along with materials needed to test—collection swabs, testing reagents and viral transport media supplies—it was also necessary to ration resources. Healthcare workers were instead advised to take their temperatures twice a day. A fact sheet for the public further advised: “A positive test will not change what a doctor tells you to do to get better” and that everyone with COVID-19 symptoms should stay home—even essential workers.

Yet while the department issues guidance to healthcare providers, the decision to test is ultimately up to those providers. That does leave some room for variation from the city’s mantra. Indeed, a random survey of five healthcare clinics and centers on Monday morning revealed that two were still offering a test, though only at the discretion of the doctor. (Another could only test patients who had appointments with doctors for procedures, such as a surgery.)

Where testing has occurred

The governor has continually placed greater emphasis than the mayor on the importance of testing—including testing for individuals outside the hospital. The state health department’s website, allows individuals to take an online assessment, a screening tool to share symptoms and be pre-registered for testing. It also informs residents that if they’ve been in contact with a case and have symptoms, they can call the state’s COVID-19 hotline for an appointment at one of the state’s drive-through testing sites. These sites prioritize “symptomatic individuals that are part of the highest-risk population, those who have been in close contact with a positive case, and, as necessary, health-care workers, nursing-home employees and first responders on the front lines.”

“Our main strategy to slow the spread of this virus has been to increase testing and reduce density in every community across the state,” Cuomo said in a statement on March 29, announcing the opening of Co-Op City’s drive-through testing site.

Prior to this past week’s announcements, there were several New York drive-in sites established outside the city, and three within the city: one in Staten Island and two in the North Bronx. Political representatives and elected officials from areas that were first to get testing sites were grateful for the state’s resources—but several-low income neighborhoods questioned how decisions were made regarding the location of sites.

Map by Dwaipayan Banerjee (MIT), fivefortyfive.net.

“My residents shouldn’t have to travel nearly 40 or 50 minutes to get to the nearest testing site—especially communities that are the hardest hit,” said Councilmember Donovan Richards of the Far Rockaways on Tuesday, prior to the announcement of additional testing sites.

Up until March 20, the greatest number of tests had been conducted in Manhattan (21,770), and less in Brooklyn (15,579), Queens (13,365), the Bronx (10,577), and Staten Island (2,658), according to an analysis of state data by City Limits. Within a week, however, cumulative testing in Queens and Brooklyn had exceeded Manhattan, and positive cases in those boroughs and in the Bronx exceeded Manhattan. While more analysis of these figures is required, it’s notable that city data one week later also shows higher hospitalization totals in Queens, Brooklyn and the Bronx.

Who’s been getting tested

As soon as the city announced its strong restrictions to ration testing supplies, it received pushback from healthcare workers, leading NYC Health & Hospitals to open up a testing program for healthcare employees. On April 1st, testing began for employees with symptoms and who are home in isolation, with plans to gradually expand the pool until testing becomes available for all NYC Health & Hospital employees on April 22.

Simultaneously, unions representing cops, firefighters and EMS officers pressed for inclusion, acknowledging the need to test hospitalized patients and healthcare workers first, but asking to be next in line. On April 3, the New York Post reported that the New York City Police Department has partnered with three health care organizations to deliver testing to officers who show symptoms. Arrangements have also been made for symptomatic members of the fire department, a FDNY spokesperson said. (As late as Wednesday a a New York Times opinion writer said E.M.S. workers had “little to no coronavirus testing available to them.”)

Many advocates in low-income neighborhoods, however, protested that they too needed targeted testing. As home to large numbers of essential workers like delivery bikers, grocery shelf stockers, cleaning staff and homecare workers, advocates said there is a much larger potential for community spread than in high-income neighborhoods, where more people work from home. And with residents still obligated to make rent, they argued it’s not realistic to expect wage workers to stay home for weeks on end. There have also been reports of employers demanding evidence of COVID-19 before granting paid sick leave.

“They’re [more] willing to jeopardize their health, than to go into the shelter system, and [they need] to feed their kids,” says Richards.

Diana Hernández, a professor of sociomedical sciences at Columbia University, says she heard about a super of a building who insisted to residents—and to himself—that his mild flu-like symptoms were not COVID-19, even though he hadn’t had the opportunity to be tested. His company was only willing to give him a few days of vacation time, and it was only because the entire building (of mostly affluent residents) came together to pay his salary that he was able to take a month off. It’s not that he wanted to put people at risk, Hernández says; it was that out of economic necessity, he made the assumption it was only the flu.

“If we’re assuming that folks that are on the frontlines and are first responders need to be tested, that logic also needs to apply to people who are [low-wage essential workers],” she argues. “If we deny people the opportunity to test, we deny them the opportunity to protect themselves and others.”

Advocates also stressed that neighborhoods with high rates of vulnerable, immunocompromised individuals—neighborhoods with poor health outcomes—ought to be prioritized for testing sites. In other words, not just the elderly population of Co-Op City, but neighborhoods with poor health outcomes, since immunocompromised people living in dense settings could easily become fatalities of the illness.

Indeed, the Center for Disease Control and Prevention (CDC) advises that after hospitalized patients and symptomatic healthcare workers, “Priority 2” for testing should be not only symptomatic first responder, symptomatic patients over 65 years old and symptomatic patients in long-term care facilities, but, just as equally, symptomatic patients with underlying conditions.

Others argued knowing where the cases are most prevalent would also help to provide important information that could inform future emergency preparedness plans. And, advocates noted, there need to to be testing sites accessible to residents without cars.

Dr. Neil Calman, the CEO of the Institute of Family Health, says that while both testing supplies and PPE remains limited and the disease remains widespread, it would not be the best use of resources to test someone who is asymptomatic, as someone who tests negative today could test positive tomorrow. He agrees, however, that in cases where a test might shape a symptomatic individual’s action—say a delivery worker with a cold and slight fever who doesn’t know whether or not to stay home and isolate himself—a test might be useful.

What’s next?

On Thursday, the governor announced his five new NYC-based testing sites in communities of color, including three walk-in facilities at health care centers. The centers will be by appointment only, and will prioritize individuals from among the highest risk population.

While de Blasio at first said more testing kits would be needed before any new populations could be reached, by Sunday he had committed to do the same—to open five new testing sites in communities of color, contingent on his ability to secure more tests and PPE. He promised more information in the coming days.

“Our goal is to reserve enough PPEs to make sure that we can do this testing properly. And then with the testing supply we have now, to see how much of it would be available to put into this new effort while simultaneously working federal government and private market to get more testing,” De Blasio said. “We feel good about, at this hour, that we’re going to be able to get this plan moving by end of the week. Although … different sites may start at different times. If we need to vary the days of start a bit because of supply, we will.”

De Blasio and Cuomo do generally share the same view on what should come next: a major increase in testing capacity that, along with other ongoing strategies, will help take New York slowly back to a state of normalcy.

The state has developed and approved an “antibody test,” and intends to secure federal approval to scale it up widely. Such a test could indicate whether a person has already had coronavirus. There are also commercially available “rapid tests,” which can ascertain whether a person has COVID-19 within 15 minutes, but need to be brought to scale. The State along with the governments of New Jersey and Connecticut are currently seeking to partner with private companies to produce these tests in the millions. Cuomo says the key to returning people back to work will be to test them, and has urged the federal government to use the Defense Production Act to mandate private entities participate in the production of tests. He also announced an executive order on Sunday to expand who is able to conduct an antibody test.

The unknowns

During press briefings on Wednesday, De Blasio stressed his interest in widespread availability of antibody tests, while also acknowledging the unknowns.While doctors remain unsure to what extent people achieve immunity, there is hope that it would at least mean short-term immunity for an individual, potentially allowing them to go back to work. During press briefings on Wednesday, Dr. Oxiris Barbot, the commissioner of the city’s department of health, alluded to this lack of knowledge.

“I agree [that] on the individual level that it can help in a number of different ways. However, when we think about we’re going to do with the results of those tests at the population level, I don’t think we know enough yet about what it means with regards to immunity,” the commissioner said. “What does it mean to have a whole group of people who may potentially be immune? We just don’t know enough about that. We don’t know enough about how long that immunity remains.”

De Blasio continued to emphasize the importance of testing as part of a return-to-normalcy strategy at his Thursday press briefing: Once we’ve reached a “low transmission phase” with fewer people with the virus, he suggested, it will be useful to once again begin tracing cases—but this will only be possible with more test kits. On Friday, he said we’ll eventually need to work up to universal capacity: having a test available whenever we need it.

“Testing, testing, testing, number one, we need a whole lot of testing,” the mayor said Thursday. “We need the federal government to step up.”