When it comes to COVID-19 testing, North Dakota is the best Dakota, and one of the top states in the nation. But why?

Shortly after North Dakota’s first case of COVID-19 was confirmed in mid March, Gov. Doug Burgum started promoting a now-familiar idea.

He said the key to minimizing the harm caused by the state’s outbreak of COVID-19, and making decisions about when to close schools and businesses, would be testing for the virus — and lots of it.

Now, testing is a point of pride for Burgum and state health officials. As of Friday, May 29, North Dakota ranks third in the nation in state testing per capita behind only New York and Rhode Island, according to the COVID Tracking Project.

“(Testing) is the foundation for the health and safety of our citizens,” Burgum said earlier this month. “It’s the foundation for the North Dakota Smart Restart and safely reopening the economy, and testing going forward is how we’re going to be getting people back into schools.”

With plentiful testing in the state, the more relevant debate has been over where it’s taking place. Some residents of the Fargo area, the state’s most populous city and the home to most of its COVID-19 cases, have said they’re frustrated more testing isn’t happening in their neck of the woods.

If more COVID-19 testing is better, North Dakota’s approach has paid off. It stands in sharp contrast to the approach taken by its neighbor to the south. In South Dakota, a state with similar demographics and political culture but a slightly larger population, testing is better than the regional average but lags far behind its northern peer.

South Dakota officials have supported expanded testing by non-public labs, but the state lab only recently became a major player in statewide testing capacity. As of Friday, South Dakota ranks 27th among states and Washington, D.C. in per-capita testing.

Gov. Kristi Noem has regularly said making sure the state has enough personal protecting and testing supplies is a top priority. But unlike Burgum, she has downplayed testing’s importance to public health and hence, her policy decisions, saying it's more important to track hospitalizations due to the virus.

“I don’t think testing is the only answer to making sure life can go back to normal, because testing someone is just a snapshot,” Noem said in an May 14 radio interview on South Dakota Public Broadcasting. “I don’t want to give people a false sense of security that having a lot of testing is going to keep them safe.”

The result of each state taking a different approach to testing is stark. South Dakota has run just under half of the number of tests processed in its lesser-populated northern neighbor. While North Dakota has run 89,599 total tests as of Friday, South Dakota has processed just 40,632 tests, fueled largely by several mass-testing events in May.

As of Friday, North Dakota has 2,520 known COVID-19 cases and 59 deaths. South Dakota has 4,866 COVID-19 cases and 59 deaths, but experts say it's likely many more cases have gone undiagnosed due to limited testing.

North Dakota state lab took lead

The central difference in the states’ approach to testing lies in the extent to which they’ve taken public control of the operation.

North Dakota has performed about 80% of all testing at a recently upgraded state laboratory, while relying on private providers like Sanford Health and the Mayo Clinic to a lesser degree.

By contrast, South Dakota has chosen to act as more of a facilitator, distributing testing supplies to in-state private health care provider labs. Those labs, along with contracted out-of-state private labs, have conducted the bulk of testing in the state.

North Dakota National Guard troops conduct COVID-19 testing at a drive-thru mass testing for  for close contacts of those who have tested positive for COVID-19, essential workers and first responders.  Photo by Eric Hylden/Grand Forks Herald
North Dakota National Guard troops conduct COVID-19 testing at a drive-thru mass testing for for close contacts of those who have tested positive for COVID-19, essential workers and first responders. Photo by Eric Hylden/Grand Forks Herald

The strategy employed by North Dakota has multiple benefits, said Brig. Gen. Robert Schulte, who leads the state’s testing operations. The state lab in Bismarck is closer to where tests are administered than most private labs, and it gives state and local officials more control over the testing process. It also allows the state to improve the infrastructure of its own health department at the same time it’s fighting a pandemic, Schulte said.

North Dakota’s state lab transformed in fewer than two months from a small operation that handled mostly tests for sexually transmitted and bloodborne diseases into a well-oiled, 24/7 coronavirus testing machine.

When the first case showed up in the state, the lab could only process about 195 tests per day, but an influx of more than 80 workers, about 15 new testing machines and millions of dollars quickly brought the daily figure into quadruple digits.

The lab burned through its entire $4.6 million annual budget by mid May, but federal emergency grants worth more than $40 million will keep operations funded through the end of the year, health department spokeswoman Nicole Peske said.

South Dakota lab supplied others

North Dakota’s lab actually started with less funding than its South Dakota counterpart, which had a $7.7 million budget.

South Dakota testing for COVID-19 was at first limited to only its public health lab, which had very limited testing capacity further restricted by nationwide shortages in testing supplies.

But testing accelerated when South Dakota-based health systems Sanford Health, Avera Health and Monument Health set up their labs to test for the virus. Still, testing remained limited when compared to what was taking place just across the border in North Dakota. Statewide, about 334 tests were processed a day through May 1.

South Dakota can now process up to 3,240 tests in the state each day. Until recently, the bulk of that testing took place in the labs of the state’s largest health systems: Sanford Health and Avera Health. But the state lab recently brought new equipment online, allowing it to run about 1,500 tests a day — or just under half of the statewide capacity.

Avera Health lab workers test for the coronavirus in this image submitted March 23, 2020. The Sioux Falls, South Dakota-based health system has the ability to process up to 200 tests a day. (Submitted/Avera Health)
Avera Health lab workers test for the coronavirus in this image submitted March 23, 2020. The Sioux Falls, South Dakota-based health system has the ability to process up to 200 tests a day. (Submitted/Avera Health)

Noem has said the state is seeking to boost capacity to 5,000 tests a day, although that likely includes testing conducted by out-of-state labs.

Yet testing in South Dakota has yet to top 2,000 tests a day, breaking over 1,000 a day only when it has conducted several mass-testing events including a four-week effort, underway now, to test all residents and workers at elder care and assisted living facilities.

“When comparing South Dakota to North Dakota, it’s important to remember that our goals are different,” said Derrick Haskins, a spokesman for the South Dakota Department of Health, in mid May. “South Dakota’s strategy for increased testing has focused on the development of sustainable clinical testing capability statewide, while focusing the public health laboratory’s efforts on providing support for critical high-risk populations.”

Meanwhile, North Dakota has regularly been processing 2,000 tests a day, driven by nearly 150 testing events at nursing homes, jails and homeless shelters. A recent spate of 1,000-test days was considered missing the mark and attributed to the Memorial Day holiday. The state has since gotten back on track, announcing nearly 3,000 test results on Friday.

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