Potential High-Leverage and Inexpensive Mitigations (which are still feasible) for Pandemics

post by Davidmanheim · 2020-03-04T17:06:42.972Z · score: 41 (24 votes) · EA · GW · 10 comments


  1) Enable people to stay isolated effectively.
  2) Triage and manage medical care remotely.
  3) Manage critical services through disruptions.
  4) Ensure transport systems remain functional.

A little over a year ago, I started a collaboration with David Denkenberger essentially trying to answer the question of what can we do to prepare for pandemics, focusing on things that are Important, Tractable, and Neglected. The resulting paper, entitled "Review of Potential High-Leverage and Inexpensive Mitigations for Reducing Risk in Epidemics and Pandemics" has now been accepted for publication. The publication process is unfortunately very slow*, but in addition to talking about a number of the things we should have been doing before COVID-19 hit**, there are a few that we are perhaps not too late to address.

I thought it was worth considering a few of the still-relevant needs and activities that seem like potentially high-leverage avenues for investigation. Given that a few of the things seem still neglected, but are potentially addressable for the current pandemic are, I wanted to highlight them.

1) Enable people to stay isolated effectively.

People are currently being told to stay in quarantine if they were exposed. Unfortunately, staying home may become more difficult if people in isolation need supplies and have no income to allow them to purchase things, or if they cannot get certain things - many medicines must be picked up in person, and in some places, supplies cannot be easily ordered online. Furthermore, if delivery services are interrupted, (which is likely given the heightened risk of exposure for delivery workers, see below,) this will become more difficult. Contingency plans to help deal with the challenges would be helpful, and systems to enable volunteers to assist could also be a useful avenue of research.

2) Triage and manage medical care remotely.

Much medical care does not require hospitals or emergency rooms, but they are utilized anyways - that's where the doctors are. If medical facilities become overwhelmed, many of these need to be replaced by alternatives - self-administered diagnostics, systems to enable phlebotomy and similar testing without needing to go to hospitals, and similar. EMTs may need to be trained to do pre-hospital triage rather than bring lightly injured patients, or people at high risk of serious infection, to hospitals. Similarly, to the extent that people can self-treat, videos and instructions for doing so may be valuable.

3) Manage critical services through disruptions.

Many people doing preparation for large scale disruptions have pointed out that it seems unlikely that their homes would lose access to electricity or clean water. The reason this is true is that these critical services will have a high priority. It is unclear, however, how much redundancy and backup exists for key personnel in this type of facility. If all of the senior engineers who can accomplish a critical function are simultaneously absent, they cannot be replaced easily during a crisis - and they are somewhat likely to all be exposed and become sick around the same time.

4) Ensure transport systems remain functional.

If international shipping is slowed or stopped, or trucking or other transport were disrupted - either due to quarantines, or because of a lack of personnel, the US food supply systems would be reduced to a fairly short supply of goods. Similarly, if Amazon, UPS, or other delivery companies can no longer deliver goods, many systems that rely on the ability to reorder components. This is a critical need, and it is unclear how the system would cope with a large scale unavailability of drivers.

To conclude, I'll mention that I'm hopeful that the discussion can start to shift towards preparation for contingencies before it becomes obvious that they are needed. Hopefully, this is something people can still lead and be proactive, rather than reactive.

*) The paper was submitted to the International Journal of Emergency Management in June, got desk rejected without review in October, and was submitted again in November to the Journal of Global Health Reports. It's now accepted - slightly too late for it to be timely for COVID-19 preparation, but hopefully in time to suggest some new ideas about response.

**) Most of the paper was pointing to a number of no-longer-neglected but more clearly important issues, such as the likelihood of shortages of supplies like masks, and talking about how companies should look at how they can enable remote work in advance to allow self-isolation. Still, there are quite a few points in the paper that aren't yet being discussed that still seem valuable.


Comments sorted by top scores.

comment by Denkenberger · 2020-03-05T05:13:52.734Z · score: 4 (3 votes) · EA(p) · GW(p)

Depending on how the situation develops, I think our suggestions about homemade versions of masks, gloves, etc. could also be useful. Hopefully we do not get to the point of loss of critical industries and needing backup plans.

comment by avturchin · 2020-03-05T11:39:34.245Z · score: 1 (1 votes) · EA(p) · GW(p)


comment by Denkenberger · 2020-03-05T21:46:23.194Z · score: 3 (2 votes) · EA(p) · GW(p)

Same as in the post above here.

comment by Tuukka_Sarvi · 2020-03-06T04:55:47.300Z · score: 3 (2 votes) · EA(p) · GW(p)

Thanks for the article. I had an idea related to your category number 2 Triage and manage medical care remotely which I also posted to another forum article as a comment [Please delete this comment in either of the articles if it is unnecessary in two places] :

If it were possible to make a home test kit for COVID, I think that would be helpful. By home test kit I mean an arrangement where people could order these tests by phone or from Internet and they would be mailed to them. Then the person would proceed to take a test sample according to the instructions in the kit and mail it back to the laboratory. The laboratory would test the sample and give the person the results via phone or web.

This kind of arrangement would allow people suspecting that they might have COVID to self-quarantine until they have a certainty (or near certainty since no test is perfect) whether they have the disease or not. Thus, it would lead to less people being exposed to potential early-stage COVID carriers and hinder the disease from spreading. Importantly, it would also protect the health care workers as they would have to come to contact with so many potential COVID carriers.

comment by Davidmanheim · 2020-03-06T08:22:02.969Z · score: 1 (1 votes) · EA(p) · GW(p)

There is a lot of discussion in the literature about setting up local testing centers, and a significant drawback is that even staffed with nurses and trained volunteers, there are real quality control and process issues. Given that, I can't imagine that home testing wouldn't have far larger problems. For example, if samples weren't gathered and handled exactly correctly, I'd expect the false negative rates could be incredibly high, and people who would otherwise self-isolate or get tested correctly would assume they could go out.

comment by AlexanderSaeri · 2020-03-05T09:26:13.007Z · score: 1 (1 votes) · EA(p) · GW(p)

If you haven't already, please upload a version to the open science framework as a preprint: https://osf.io/preprints

comment by Davidmanheim · 2020-03-05T11:03:01.051Z · score: 3 (2 votes) · EA(p) · GW(p)

I have uploaded it to preprints.org, linked above, pending the final layout and publication. (With an open source license in both cases.)

comment by ishi · 2020-03-05T14:56:48.453Z · score: -5 (3 votes) · EA(p) · GW(p)

To me this paper looks like 'common sense'. Its good to write down 'common sense' but its not 'rocket science'.

(Since i sometimes go hiking or backpacking or on a bike trip i try to keep a list of things i need to take with me--i can basically remember these or recreate the list in my head-- but its useful to have a written down checklist--but its basically common sense.

The same is true for phone numbers, addresses, email adresses, computer passwords, the value of fundamental or mathematical constants like c or pi or e, etc. Those of course best be written down.)

I do like the emphasis on 'prepare to DIY' (do it yourself). If i recall one of the authors lives in Alaska--i checked the weather in AK today and temperatures ranged from -30F to -40F in the areas i lived in for awhile. In that area (miles from the nearest town and you couldn't drive to that town in winter) you had to be prepared to DIY. For example---make your own gloves---when i lived in Alaska i made my own gloves and overshoes (like mocassins) from mooseskin someone gave me--my feet were never cold. Its what the indigenous Athabascan indians wear in winter ).

The only issue I have with this is I occassionaly go to a hospital or some other thing---sometimes a 'planning meeting' . I usually go to a hospital if i've broken my wrist or ankle on a hike--i usually try to do DIY healthcare to fix these broken bones but eventually i seek professional help. (Some times they tell me actually its not broken , just fractured, so i just need a cast.) But also there is alot of buerocracy in these hospitals with paid staff, so you people tell you how to tie your shoes, what a 'healthy diet ' is (i'm basically a mixed vegetarian/vegan), and why i should excercize.

In 'community planning meetings' people can spend and hour in a discussion and some paid professionals will write 'policy memos' or 'white papers' on the pros and cons 0f having a community park' or 'bike lanes' if they are planning some new commercial development.

These paid professionals are usually government employees, who sometimes get paid the same amount as a rocket scientist (to write an article on whether you need a community park)

Thats not rocket science either, its common sense. (Though some people oppose community parks--they (usually the owners of the land) view those as wasted land they could put more commercial development or condominiums on. And a few local residents dont want a community park because these attract noisy children and sometimes homeless people and drug addicts).

Its just seems like too much beurocracy--- if people had common sense they could DIY. I dont need an academic paper explaining how to tie my shoes. (I did need to learn that long ago ---but my parents taught me that---maybe some people who are adults do need to read peer reviewed academic papers to learn things like that. Also, why you should 'wash your hands' and 'clean your room'. Perhaps there should be PhD programs in these areas. )

Since the guidelines for this forum say 'be kind', I am sort of pointing out a problem with academic problem--which is one reason alot of open access journals and working paper sites and blogs exist. Noone wants to wait to go through a long peer review process, nor pay to get beyond a paywall to publish or read papers which are mostly common sense. 'How many economists does it take to screw in a lightbulb?'.

comment by Denkenberger · 2020-03-06T03:54:55.862Z · score: 5 (4 votes) · EA(p) · GW(p)

Yes, this morning in Fairbanks it was -32F (-36C)!

Though many of the recommendations seem like common sense in retrospect, the reality is that these interventions are relatively neglected. We would have been better off if we had done some planning ahead of time about how to scale up personal protective equipment (PPE) such as masks. Furthermore, common sense varies. For some, it is common sense that a mask will protect you from illness, but people do not realize that the pore size of a simple polymer surgical mask is significantly larger than most evaporated cough/sneeze droplets. At the other end of the spectrum, common sense might lead you to believe that an improvised fabric mask would be ineffective because the pore size is larger than the typical surgical mask made of polymer. And indeed the median particle that is sneezed would go through a fabric mask. However, when you look at the droplet size distribution, the majority of mass (and therefore viruses) are actually contained in the larger droplets that would be stopped by a fabric mask. Similarly, common sense might lead you to believe that a glove needs to be rubber because that is how we get most of them. But if dexterity is not critical, one can use plastic (e.g. garbage bags). Another piece of common sense that I had before embarking on this project was that this PPE would just slow down the spread, but eventually everyone would get the disease, so the mortality at the end would be the same (assuming a vaccine is not developed in time). But in reality, since people who have had the disease generally have immunity, the number of people that infected person spreads to eventually falls below one, and the virus dies out, not infecting everyone. So these simple PPE interventions could actually significantly reduce overall mortality. Furthermore, if people can do more distancing early on, the spread of the virus could be stopped early, preventing a pandemic. So there really is a lot that we can do on the non-medical side.

comment by ishi · 2020-03-06T19:48:33.753Z · score: -3 (5 votes) · EA(p) · GW(p)

I agree with you. 'common sense is not common sense'. (I personally am on a special diet--this means i mostly have to eat vegetables, but other people i know always say 'you need some protein or meat--that's common sense' . i do feel good if i eat some, but next day i wake up sick as a dog. so i avoid it. )

the only issue i had was most people do not read J Emergency management. everyone lives in a 'filter bubble'.

https://arxiv.org/abs/2003.00107 (and more like that) https://arxiv.org/abs/2002.03268

I had to look up PPE--personal protective equipment. )

I view plastic garbage bags as an almost neccessary thing to carry ( large ones. medium size and small ones --they keep everything dry --small ones are good for papers and books; medium ones are good for extra clothes, and big ones can serve as a rain or snow poncho or tent . I am aware of the environmental consequences of all this plastic but for now i still use them).

When i was in Alaska i lived a 6 mile walk down the frozen Yukon river (in winter ) from Eagle (near the canadian border) . In summer i stayed somewhere else in same area. it seemed like it could go from 80F in summer to -45Fp or colder in winter.

My current area used to be the 'murder capital of the USA' ( but now we have lost that title to Baltimore ) but now its the 'bedbug capital of the world' . (There are radio shows on the local NPR affiliate WAMU on this bedbug problem ---i even had it recently ---i dont know how they got in here--maybe some of my guests had them on their clothes and there are also mice in here. This plastic kills these bedbugs.

(Its required in my area that if you throw out a bedbug infested matress you have to enclose it in a big plastic bag).

The neighboring state (maryland) has just declared a corona virus (or covid) state of emergency . I think they only have a few confirmed cases.