On August 20, 2026, a nurse practitioner at a free clinic in Lee County, Florida told a television reporter that her clinic is not testing anyone for cyclosporiasis, because it serves mostly uninsured patients and the test costs them hundreds of dollars. Her clinic has seen cases anyway, in patients and in its own staff. None of those people were tested, which means none of them are among the cases Florida has reported this year. The same day, NPR published an account of what has happened to the people whose job it is to find cases.  I want to go back to bed and hide.

A clinic in the county with the most cases in southwest Florida is not testing anyone.

The clinic is Samaritan Health and Wellness Center, and the nurse practitioner is Susan Hook. Speaking to Gulf Coast News Now, she described patients passing more than twenty stools a day before seeking care and said of testing: We are not testing anyone. Her reason was not clinical. It was that her patients are uninsured and the test is expensive for them to reach. Lee Health hospitals in the same county do offer the test, with same-day results. The test exists. It is a few miles away. It costs what it costs.

The arithmetic behind that price is worth stating plainly. Cyclosporiasis is not found by a routine stool workup; a provider has to order it by name, and because the parasite is shed intermittently, CDC advises that a single negative specimen does not rule it out and that three specimens are optimal. Public laboratory fee schedules put a single direct examination for this parasite above one hundred dollars. Multiply by three, add an office visit, and the barrier is not abstract. Florida is at 460 cases through August 15, with 39 in Lee County and seven in Collier.

Nobody has measured how often this is happening, and no mechanism exists to measure it.

There is no survey of clinics, no state reports how many symptomatic people went untested, and this is the only named instance I have seen all summer. It is worth being precise about what it does and does not show: this is one clinic making a decision about cost, not a state policy of refusing to test the uninsured. But it is the first time anyone has put a name and a place to the thing every surveillance page hedges about when it says the true number is higher than the number reported.

Two facts frame the size of the hole. First, CDC’s 11,841 pending cases are all people who were tested; the backlog is a laboratory queue, not the missing population. Second, the standard estimate of the gap comes from Scallan and colleagues, Foodborne Illness Acquired in the United States, Major Pathogens, which puts the underdiagnosis multiplier for Cyclospora at 83.1. That multiplier has always been treated as a fact of nature. Part of it is a fact of billing.

The people who would do the counting are being cut.

NPR reported the same day on what has happened to the capacity behind these numbers. Bob Custard, president of the West Virginia Association of Sanitarians, says about half the positions on his state’s food safety organization chart are vacant, that one growing county went from four sanitarians to two and lost its only epidemiologist, and that West Virginia lawmakers responded in March by lowering the education requirementfor the job from a four-year degree to an associate degree. His summary of the national approach to foodborne illness: It is like we have a house, and we decided to take smoke detectors out.

The rest of that reporting is worse. Kentucky says its food safety staff is down thirty to fifty percent. Susan Mayne, who ran FDA’s food center until three years ago, says the teams that coordinated crisis response with foreign regulators were eliminated and that she does not know who is managing the relationship with Mexico now. Dan Jernigan, who ran the CDC center over the parasitic diseases laboratory, says that laboratory lost much of its funding when USAID closed, is missing at least a third of its staff, and is now triaging to multistate outbreaks when it used to help states with every one. Two USDA parasitology laboratories in Beltsville were told in May to relocate or lose their jobs, and their work has effectively stopped. In fairness, and it belongs in the same paragraph: Ohio says its response is unaffected, Michigan went to court and kept its grant money, HHS says the CDC laboratory supporting this response was not cut, and USDA says its research continues without disruption.

Things worth asking before I try to get some sleep, and they are answerable this week.

Will the Florida Department of Health run this test at no charge for a symptomatic uninsured patient, through a county health department or the state laboratory, as part of an outbreak investigation? State public health laboratories commonly do outbreak testing free. If Florida does, the failure is that the clinics treating the uninsured do not know it, which is fixable in a week with an email.

Will CDC put this parasite back into FoodNet? It was dropped last year along with five others, and it is the only system that produces a stable estimate of whether things are getting better or worse.

And will the agencies say what the genotyping shows? CDC said this week that it can group these parasites genetically. That capability sits in the same laboratory that has lost a third of its staff.

I have spent a month counting this outbreak state by state, and I have been treating the count as a floor because of reporting lag and because people recover at home without seeing a doctor. Add a third reason. In at least one clinic, in the middle of the largest cyclosporiasis outbreak this country has ever recorded, sick people are not being tested because of what the test costs. The parasite does not care whether anyone counted it. It is the rest of us who need the number.