As Alabama’s confirmed cases of coronavirus rise into the double digits, swaths of the population have so far remained cut off from testing.

Why?

1. We’re still rationing tests

Circuit Judge David Carpenter in Jefferson County recently posted on Facebook that he’d been exposed to someone who tested positive for coronavirus. He found that the freestanding test clinic in his area was closed on the weekend.

“The state coronavirus hotline recommended I get tested at an ER,” he wrote. “The ER doesn’t have enough tests. I am quarantined.”

The shortage of tests is a national problem, reported in several states. And without enough testing, Alabama and the United States can’t really know how many people have the coronavirus.

The state relaxed the rules for who could be tested for coronavirus late last week, but that decision didn’t come with an increase in testing supplies. Alabama hospitals and other providers are having to pick and choose who gets tested.

Don Williamson, executive director of the Alabama Hospital Association, said some hospitals around the state have reported testing supply shortages. Some hospitals don’t have testing supplies at all. Harris, in a press conference Tuesday, called the shortage of testing swabs a particularly “acute issue."

Dr. Michael Bindon, an emergency physician at Springhill Memorial Hospital in Mobile said he’s spoken with ER doctors from around the state in his capacity as president of the Alabama chapter of the American College of Emergency Physicians.

“It can be frustrating to patients, but there are a limited number of tests, and most of the hospitals and emergency physicians have criteria” to determine who gets a test, he said.

“If we only have five test kits left, you’re not going to use those on asymptomatic patients who think they might have been exposed.”

2. People who might have coronavirus aren’t getting tested

When testing is limited, many people who may have the virus may not realize they’re transmitting the disease because they haven’t been sick enough to get tested or don’t live near one of the state’s few testing clinics.

“The most efficient vector of this disease is the young and healthy population (that) may not know they have it,” said Brian Hastings, director of the Alabama Emergency Management Agency, at a state press conference Monday morning.

Read more: Why were so few people in Alabama getting tested for coronavirus?

Bindon said it’s a conversation emergency room doctors have been having with patients over and over:

“We’re saying to them, ‘There’s a decent chance you have COVID-19 but we’re looking at whether you’re sick enough to require hospitalization or well enough to go home,’” he said. “If you’re in a hospital without enough tests and you aren’t sick enough for hospitalization, we’re going to say you need to go home and quarantine for the next 14 days.

“That’s a tough message to receive. If you’re going to self-quarantine, you’d like to know you have a disease, not just that you might have it.”

State Health Officer Scott Harris said Monday there is no reason to test someone who does not have symptoms of COVID-19, but said there isn’t data available to show how long a person might be contagious before or after symptoms occur.

South Korea, a country with a significant population of infected people but a very small death rate, has been praised by world health leaders for its response to the coronavirus outbreak. The country quickly set up a network of testing sites and has been testing nearly 20,000 people a day.

By contrast the United States, a country with six times the population of South Korea, has tested about 39,000 people total as of Monday morning.

3. There are backlogs at the labs On Saturday, Jacksonville State University released a statement saying university officials had hoped to be able to share results of COVID-19 tests that had been performed on two students, but still didn’t have the test results. This announcement came more than a week after two JSU students were placed under quarantine after possible exposure to coronavirus in another state.

“Unfortunately, at this time, all of (the private labs performing coronavirus testing) are overwhelmed with tests to run,” said the release. The school found out Monday that the tests were negative.

Even as private companies like LabCorp, Quest Diagnostics and Assurance Scientific Laboratories began processing test kits and returning results last week, there’s evidence demand is outstripping capacity.

“We’re already getting feedback from private labs that we’re getting close to capacity and may not be able to accommodate the volume starting to come in,” said Bindon. “There’s a bottleneck.”

Harris said Monday morning that there was not a concern about not being able to test samples. The Alabama state lab, at least, does not have any issues with backlogs, he said.

“We are able to test all the samples we receive on the day we receive them,” he said. “We don’t have any concern about capacity right now.”

4. Too few testing sites

Right now, most of the Alabamians who have been tested for COVID-19 live in Jefferson County, Harris said. This is where Assurance opened two drive-through testing locations late last week.

Jefferson County also has the highest number of confirmed cases in Alabama.

“That’s not surprising,” said Harris, because “Jefferson County has also had the most access to testing.”

As drive-thru coronavirus testing centers have popped up or are in the works in Birmingham and North Alabama, the rest of the state has one main option for testing: the emergency room. And emergency rooms around the state aren’t always equipped to administer a large number of tests.

“In the southern part of the state we’re at a bit of a disadvantage,” said Bindon on Sunday. “It’s been radio silence down here. If you’re a patients and don’t have those remote sites and your primary doctor isn’t seeing you, there’s really not a good answer right now.”

Read more: Here’s where you can get tested for coronavirus in Alabama

Harris said Tuesday morning that the state health department had opened six testing sites and hoped to open 5-10 more by the end of the week.

The barrier to opening testing sites, he said, “has been being able to obtain supplies like personal protective equipment, swabs for testing and the like.”

Bindon said he and other emergency room doctors are optimistic about the opening of more testing sites in South Alabama, “But it can’t happen soon enough.”

Why does it matter? Because a lack of testing could break Alabama’s hospital system

If COVID-19 isn’t kept in check, even a small percentage of Alabamians needing hospitalization could overwhelm the state’s hospitals.

Bindon said most hospitals seem to have the equipment they need right now, but he’s concerned that won’t be enough.

“Based on how this has played out internationally, we know we’re at the very beginning of (the epidemic),” he said. “If you look at the mortality data from other countries, it’s not bad at the beginning but (the death rate) starts going up as the hospitals get overloaded and are no longer able to keep up.”

Harris said the state is tracking daily the number of beds and ventilators being used at hospitals around the state through an online reporting system. He said there hasn’t yet been a surge.

“We know we have a great hospital,” said Bindon, “but no healthcare system out there is set up to deal with 300 to 400% increases in patients needing ventilators.”

Bindon, when asked what could help him and other healthcare workers do their jobs better, said it comes back to community buy-in on recommendations like social distancing, washing hands and avoiding crowds.

“Italy was a decent healthcare system that got overrun,” he said. “That’s what we’re all trying to prepare for. Whether this goes to a level like Italy or whether we get more of a South Korea situation, a lot of that is going to depend on how seriously the public takes it.”

Here are our live updates on the public health crisis in Alabama. You can find all of our coronavirus stories here.