The Roadmap to Pandemic Resilience

Led by Danielle Allen and Glen Weyl, the Safra Center for Ethics at Harvard has put out a Roadmap to Pandemic Resilience (I am a co-author along with others). It’s the most detailed plan I have yet seen on how to ramp up testing and combine with contact tracing and supported isolation to beat the virus.

One of the most useful parts of the roadmap is that choke points have been identified and solutions proposed. Three testing choke points, for example, are that nasal swaps make people sneeze which means that health care workers collecting the sample need PPE. A saliva test, such as the one just approved, could solve this problem. In addition, as I argued earlier, we need to permit home test kits especially as self-swab from near nasal appears to be just as accurate as nasal swabs taken by a nurse. Second, once collected, the swab material is classified as a bio-hazard which requires serious transport and storage safety requirements. A inactivation buffer, however, could kill the virus without killing the RNA necessary for testing and thus reduce the need for bio-safety techniques in transportation which would make testing faster and cheaper. Finally, labs are working on reducing the reagents needed for the tests.

Understanding the choke points is a big step towards increasing the quantity of tests.

Comments

Congratulations!

Stand Up and Take a Bow!!!

It is always more reassuring, and more valuable, to have worked with others.

Over 20 co-authors and not one epidemiologist! Economists master race!

They didn't have an epidemiologist on board because they were worried about contagion and transmission of ideas. Actually, though, they did have people from Harvard's school of Public Health,

But, their crowning achievement, accounting for the success of the project, was the presence of lawyers on the panel.

You're a moron. Without Jesus, none of these tests will work correctly.

The implied assumption is that the new groups, organizations, and infrastructure required by their approach will be much more competent than our existing FDA, CDC and similar health departments have demonstrated.

Having individuals, businesses and institutions set up their own biosecurity policies and procedures to reduce the "socially constructed" reproductive rate Re of the virus requires the transfer of knowledge to the people on the details of how this virus is spread and how to block that spread. It is all about social change impacting the Re.

Such biosecurity plans and protocols are common in many animal husbandry businesses. For example, producing SPF (specific pathogen-free) shrimp requires detailed biosecurity procedures and protocols that make our hospitals look like pig pens of pathogens. We know viable and lethal viruses exist in frozen shrimp and fresh shrimp, so protocols ban employees from eating or being around fresh or frozen shrimp at any time. Consultants can't have visited another shrimp hatchery in three days and when you do enter your shoes go through foot baths along with the usual hand washing and external coverings. Sneezing is not a transmission mechanism of relevance so face masks are not included.

Looking at the details of transmission and blocking those paths will be much more effective, but won't create powerfully bureaucracies. I was shocked by the viewpoints of the authors about how rationally they expect bureaucrats to behave.

minor mistake - RNA not DNA

Picky, picky, picky. That's why economists aren't epidemiologists.

Right. that's why I said it was minor

That was not an attack on your comment. Please accept my apologies if you read it that way. I just thought it was funny, and more likely the result of the poster writing at 7:25 am in the morning without having had coffee. Spellcheck makes us all look silly.

Thanks. Fixed.

"to beat the virus." There's a case for adopting a better defined target than that.

It all sounds pretty exhausting, but maybe the obituary trope of likening being ill to "fighting a brave battle" the last few decades has mentally prepared people to go all-in on such an effort. Still, one thinks about the next virus ... If people are to live more like bats, the future being cities and all, and *unexceptionable*, mainstream pundits like Matt Yglesias' calling for "A Billion Americans", etc. - will we not become host to more and more viruses? Would a biologist - not an economist, not an epidemiologist - register the same faith in this sort of process: "We need to deliver 5 million tests per day by early June to deliver a safe social reopening. This number will need to increase over time (ideally by late July) to 20 million a day to fully remobilize the economy. Achieving these numbers depends on testing innovation. We acknowledge that even this number may not be high enough to protect public health. In that considerably less likely eventuality, we will need to scale testing up much further..."

While we're at it, will we also test people for the flu, or will we treat the communicability of the flu as more an act-of-God?

I mean - it will doubtless teach us many things to attempt such a testing regime - but it seems like compliance will depend on keeping alive an unusually strong fear of the virus, the sort of fear America was not able to maintain with regard to alcohol or drugs, as T.C. alluded to the other day.

Also, I think you need to pay more attention to the reporting process - at the scale you are talking about - a sensible scale - the existing reporting process will collapse. And changes to this process are slow. It's urgent to get progress with this now.

RNA for testing, not DNA. SARS2 is a single stranded RNA virus.

I hope you make it work. There has been a lot of promises on tests. Now this saliva test, needs to be more sensitive because the viral load will be lower than with a naso-pharyngual swab.
The link says : get the result in 24 to 48 hours.
The Koreans get results in < 6 hours.
If you want to test health care workers going into a nursing home every day , I think you need a 15 min test max

Meant as a response to Alex’ post

"It’s the most detailed plan I have yet seen on how to ramp up testing and combine with contract tracing and supported isolation to beat the virus."
Yet, it confuses basic terms. Man, the arrogance of this site has been sickening over the past month.

To make that obvious. And to be honest, one has to wonder how detailed the actual Austrian plan being implemented right now is, especially regarding the 'choke points have been identified and solutions proposed.'

Yeah, the choke points section is a picture of Trump.

The proposed solutions are variations on a theme.

Here's one of the recommendations:

"Implementation of such a complex supply chain at this speed requires tight coordination most naturally facilitated
by a Pandemic Testing Board (PTB), akin to the War Production Board that the United States created in World War II. The market has not so far supplied the necessary scale of test production." See page 14.

Good for you Alex. As a philosopher once said to the effect: "No man differs more from another than he does from himself at another time." Change is good.

He too will learn to love state capacity libertarianism, as the end of the pandemic draws measurably closer with the publication of this plan.

The chocolate ration will still be left up to the market.

"State capacity libertarianism"

That's like the training-wheels euphemism for accepting the reality that it wasn't such a good idea to drown our government in the bathtub, after all?

I'm not a fan boy of everything tech, but here is the link to an article by Todd Purdum (an exceptional journalist) about California governor Gavin Newsom's, but more generally about the state of California's, including tech's, response to the coronavirus. https://www.theatlantic.com/politics/archive/2020/04/coronavirus-california-gavin-newsom/610006/

California may be exceptional because they were exposed to the Chinese strain vs. the European strain.

Link to evidence please that there is a different mortality to the strains.

There's no hard evidence of much these days, so don't set the bar higher that you would for your own evidence.

https://metro.co.uk/2020/04/21/coronavirus-mutated-30-strains-deadliest-raging-across-europe-12586269/

I saw this paper. It’s a strong claim, it would need confirming. The sample size was small ( 11) and the increased virulence was seen in vitro.
This virus comes in one long genomic strand , the flu virus RNA for example is in 8 segments which facilitates mutations due to swaps between segments.

Are you saying the flu virus has multiple chromosomes (if that is a word used for viruses)?

Viruses don't have chromosomes. They are just DNA or RNA wrapped in protein with maybe a fatty overcoat. That's it. In fact many viruses are much smaller than say a human chromosome.

I looked it up: "The vast majority of viruses have RNA genomes. ... Among RNA viruses and certain DNA viruses, the genome is often divided up into separate parts, in which case it is called segmented. For RNA viruses, each segment often codes for only one protein and they are usually found together in one capsid."

Coronavirus does indeed *sound simpler* in that way than the flu virus.

The Wuhan strain looked pretty lethal. If there's 30 strains then it is possible the luckier countries got some of the "weaker" strains.

The working hypothesis is that the different strains are not significantly different in infectiousness/potency.
This paper says maybe “ not so” We can’t just change our understanding on a dime because of one paper. However it’s a signal for scientists to look into it and validate/invalidate this new claim.

So, the team has one person with the word "health" in their title. An attorney. I understand this site is on a vendetta against epidemiologists, but were you unable to find any public health experts to join in the conversation about how to fix public health?

The conclusions seem reasonable enough, I mean, in fact it's a bit of a surprise that this paper hasn't been written several times already.

But you buried the lede. The paper calls mainly for Federal leadership and funding. That's been the missing piece all along. I am sure it's a bitter pill to admit that a robust federal response has its place, and that there are some important things the "market" can't/won't do.

20 million tests a day? Of course Quest Diagnostics and the others are going to tell you they can do it. Haven’t they already been taking on more tests than they can handle?

I don’t think the scale of testing proposed is feasible and you’d think they would spend a little more time or provide at least more detail of how the hell we are supposed to set up these 30 mega labs.

I think this is the final straw for me. I’ll stick to listening and reading what virologists and actual scientists have to say on this. The authors of this roadmap don’t have the level of technical knowledge necessary to reassure me this isn’t science fiction. Plus the people doing This Week in Virology display a certain level of humility that is frankly refreshing.

They really could have used Jared Kushner's touch to fluff up this thing with some practical details and ground truthing.

Snarky responses to critics doesn't make this plan sound any more feasible.

Well, your statement implies that you & I share a common assessment of the purpose and effectiveness of internet comments.

But I believe I was in fact agreeing with CS here; mine was bit of a 'me-too' snark. Not a snark directed at a critic. for whatever that's worth in this context.

"20 million tests a day? Of course Quest Diagnostics and the others are going to tell you they can do it. Haven’t they already been taking on more tests than they can handle?"

According to the Covid Tracking project, the backlog(pending) has been shrinking for weeks. As of yesterday:
138K new tests, Pending tests: 4K

For reference on March 30th:
119K new tests, Pending tests: 65K

https://covidtracking.com/data/us-daily

It is good to know that the backlog is shrinking. But my point isn’t simply the numbers Quest can handle — and just using them as shorthand. The point is that the people this panel asked on this particular question aren’t disinterested. They are also people probably actively dealing with the problem and a bit more optimistic about what they can do than they should be.

Maybe it is a simple issue. Maybe we’ve got all the lab machinery we need just waiting to be bought.

I’m not trying to shift arguments, but there is the whole question of if this is politically feasible. I’d like to say that it would be a no brainer. But I sort of suspect it isn’t or at least wouldn’t be for long.

They did have a person from Harvards School of Public Health on the panel. And, most importantly, they had lawyers on the panel.

Also, better weather, less density, and lower dependence on public transportation may also be factors.

Credit where credit is due, though. Newsom's stock should be way up.

Economic resilience also matters. More than 150 scholars and economists signed an open letter calling on Newsom to suspend Assembly Bill 5 during the pandemic. So far he's ignoring them.

And you are saying that's not him doing his job well? Why's that?

more testing, testing, testing, testing ...?

Testing, itself, cures nothing.

margin-of-error (false negatives especially) in current Covid-19 test "systems" is a big problem'

Nor does measuring the rate of unemployment in a society cure unemployment.

Marginal data is better than no data. What are the options here? Make choices blind or make choices with less blind? I have the suspicion that less blind is better than blind.

The Plan is Testing, Tracing and Isolation. It says that right on the cover.

Alex, has this plan been discussed with CDC and other federal government agencies before releasing it?

I wonder about that discussion because in the Introduction your report argues:
"If we rely on collective social distancing alone to tide us over until a vaccine is available, the economy will be shut down on and off for 12 to 18 months, costing trillions of dollars. We can instead fully restart the economy by August through a program of massive investment in public health infrastructure, especially diagnostic and serological testing, combined with effective contact tracing-and-warning programs, and supported individual quarantine and/or isolation."

Frankly, I laugh at the periods mentioned in the paragraph. They are political tricks to attack what the Administration is attempting to do and to please your patrons. You cannot argue seriously for those two periods: with Trump's ideas the economy will be shutting down the economy on and off for 12 to 18 months, with our plan the economy can be restarted only by August, late enough for Trump to benefit in November from opening the economy right now.

If your patrons were serious about their intentions and concerns, they would have asked you to discuss your proposals with the Administration before releasing them.

Testing?...or throw in the towel....

A new study on LA County, from USC–

“221,000 to 442,000 adults” in LA County have COVID-19 antibodies in their blood. No one knows how many additional children have antibodies to COVID-19.

There are 617 COVID-19 related deaths in the county, usually people with co-morbidities.

That’s a 0.01% to 0.03% death rate from COVID-19—but even that measures only adults. The death rate would sink if children were added into the mix. So, deaths are in line with a bad seasonal flu that struck at once.

No doubt the USC study will now be attacked or defended on its methodology, because COVID-19 is no longer about policy options, but defending one’s previous positions or even ideologies, or emergent programs resulting from the virus. Public health officials and allies are in nirvana.

Yes, this USC test will have some of the weaknesses as the earlier Stanford test (Santa Clara). But really, how long can we go with lockdowns that may or may not be effective against a virus with a low fatality rate?

Instead of undercutting epidemiologists, shouldn't economists be doing some sort of updated cost-benefit analyses?

The AEA published a study (featured in MR) that assumed 1.9 million COVID-19 deaths, attributed all the deaths to C-19 and no prorating for co-morbidities, and assumed each life was worth $10 million or so.

In those assumption, a six-week lockdown was worth it.

How about a new study assuming 400,000 C-19 deaths with some pro-rating for co-morbidities?

And $10 million a life? Yes, it is morbid to raise the topic, but how many families would fork over $10 million to save 87-year-old grandma who has co-morbidities? Would you sell your house, and go several million into debt in such a situation?

The lockdowns are poor policy.

You assume that people would have to write a $10 million check to save granny. But that's not how it works in our economy. In our economy we spend other peoples' money. Most people would indeed spend $10 million of other peoples' money to save their grandmother. I mean, they already do: what is the medicare/-caid outlay in the last two years of life? (Ok, not $10 million, but the point stands).

And despite all the pretense and kabuki, most Americans are aware on some level that when they are told it cost the taxpayers $10 million to save grandma, they are aware that we already shovel trillions towards banks and the military, so the sudden pretense of scarcity in this context is a Big Lie.

But if of course some people are willing to spend $10 million of other people's money to save other people's grandmothers!

Well, they woudn't agree to spend $10 million per day to wage a proxy war in Yemen ether. Or stroke a check for $10 million to fund a small part of Jamie Dimon's quarterly bonus.

That's why they are not given the choice.

Fairly easy to come up with a reasonable estimate for that Medicare number:

- Reportedly about 2.1 million people who die each year are Medicare beneficiaries and an estimated 25% of Medicare spending is on beneficiaries in their last year of life ( https://www.kff.org/medicare/issue-brief/medicare-spending-at-the-end-of-life/ )

- Annual Medicare spending is about $730 billion ( https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/ )

$182.5 billion divided by 2.1 million people is about $87,000 per person spent on Medicare beneficiaries in their last year of life.

So $10 million is only off by about two orders of magnitude. That seems to fit with the quality of far too much of the analysis that we're seeing about COVID-19.

Have you ever, do you think, known anyone who - at his own expense - insured his life for ten million dollars?

fwiw, $10M is the ballpark for a US wrongful death settlement.

https://www.gjel.com/wrongful-death-lawyers/average-settlement-lawsuit.html

But I agree that these are funny numbers.

Having recently gone through my parent’s death, Medicare was wonderful. My parent had outstanding insurance and Medicare on top of it which, I might add, was paid into from inception.

My parent was healthy until the last 4 months. My parent rarely got sick in general. Medicare provided everything and some things which we ended up not needing.

The staff was great, initial delivery was efficient, and no bills. Do not underestimate the comfort of that to families.

I still think Medicare needs to be overhauled, especially after this experience.

This is a learning experience. The CDC and FDA’s turf war is a harbinger.

Just because you do everything in your life to stay healthy, doesn't mean you’ll do your family and Medicare a favor and drop dead so you won’t be a burden and cost the younger generations. If my impression is wrong from reading various posts over a period of time, I apologize.

If you haven’t considered a will or updating/tuning up your will after this pandemic, you might want to.

Hard disagree that the linked site shows $10 million as anything like the "average settlement".

The linked site - a plaintiffs' law firm - specifically doesn't cite an average. They list "examples" to demonstrate their experience, and those are six settlements or verdicts ranging from $4 million up to $13.6 million. Those are almost certainly the 6 biggest dollar amounts in the history of this firm.

Pretty easy to think of reasons that $10 million isn't typical but is far higher than an average wrongful death award. How much is your auto liability insurance policy limit? I'd be surprised if it's more than $1 million.

Auto liability insurance is going to be the go-to for a heck of a lot of wrongful death settlements. (A lot of corporate claims end up in workers' comp instead - if they involve the death of a company's own employee - and in most states that's a relatively stingy system for wrongful death.)

+1 to Benjamin Cole.

Then again, when Tyler apparently has somehow forgotten that there's a financial reward to being first to market when several companies are competing to develop a vaccine - https://marginalrevolution.com/marginalrevolution/2020/04/more-simple-economics-of-a-pandemic.html - I'm left to wonder how much this blog cares about economic analysis these days.

Benjamin,
The results you cite of deaths were after LA imposed controls. The number of dead should have been the number that would have happened had they not done the controls. It is specious to use as the denominator the successful result and not the result that would have been attained had they done nothing.

Imagine if Italy or NYC had been able to control things strongly at the beginning and someone said: gee, all this money, and we only save 100 lives.

Sounds sensible but you also have examples of countries who did little but didn’t suffer runaway exponential growth. ( Japan/Sweden)
A lockdown is like a giant mask all around you. It has the disadvantage of including not just you but your household. It’s also a little porous since some essential workers need to go out.
Is it possible that just masks + no hugs , no handshakes and hand washing coupled with “ stay home if you’re sick “ directives and ban 50 + persons gatherings give you most of the benefit of the lockdown?
It seems this epidemic basically runs out of steam in 8 weeks everywhere in the world, regardless of policy.

I am completely on board, though perhaps I was not a hard sell.

Testing, Tracing, and Supported Isolation

The hard question is how we get moving, and who will pay for it. I see that page 28, on "jurisdictional responsibilities," proposes an answer to that.

I'm still a fan, and I think we should all pull together on this, but I think page 28 is a little light on who pays for the supported part of supported isolation.

AFAIK federal aid has not, but must, be oriented along these lines. Not just unemployment, or supplemental income, but straight up COVID-sick pay.

Apologies if I missed more specifics in my scan.

I have never understood the way that economists value a human life.
(My own field is health insurance, not economics.)

Here is how I value a life.

I happen to be 72 years old. If medical care for Covid-19 extends my life
by ten years, I will collect $120,000 roughly in Medicare benefits and
$250,000 roughly in Social Security.

Now I paid taxes for these programs, but the dollars I will be getting probably exceed the taxes paid, and by a lot.

While collecting $370,000 in benefits, I will pay perhaps $70,000 in federal income taxes.

Also while I live, my children do not inherit any money (though I can give gifts instead).

So where o' where do these figures of $10 million per life saved come from?

My position is that medical care for the old is a wonderful gift, but it is a gift and it is crazy to pretend otherwise.

When they use value of a statistical life (VSL) it is necessarily based on the model of a median person. Which makes it a SWAG (a scientific wild-ass guess).

But in terms of our inputs and outputs from Medicare and Social Security, I view them as a mandated life annnuity, with some but not all supplement from general funds.

As a life annuity it does have to be rejiggered periodically, as life expectancy, health costs, and the prospects of the 18 YO cohort change over time.

But certainly for the 18 YOs it isn't *just* a gift. It's a social contract that the annuity will be there for them as well.

Precisely. It is a forced savings account. And the payouts are return on investment. Not gifts

And despite nearly relentless attacks from the right to weaken and hamstring them, the programs persist. Because they work.

The only problem with Medicare is the GOP efforts to extinguish it, plus the refusal to control health care costs at the provider level.

Medicaid, meanwhile, is arguably a gift. If you are inclined to think of helping the less fortunate among us a gift. And can look past the fact that our system requires less fortunate people by design. And ignore the fact that the elder care system is designed to impoverish its participants, also by design.

I think it's important to emphasize the death-pool aspect. Not everyone who pays in gets money out. You have to survive to retirement age. And then your ultimate payout is based on survival again.

So it's not just our money we get at 72, it's also from all the hommies we lost along the way.

That's correct. Survivors benefits aside; it's more like an annuity plan than a true savings account.

The $10 million is a fairly inflated number. Essentially, it's a high level mark, where if you are spending more than that per person, then the spending is inefficient and would be better off directed elsewhere.

So don't look at it as the "value" of a life, look at is a wasteful spending indicator.

My point was that spending $5 on the elderly might be technically inefficient. Using my rough number of $370,000 going out over 10 years and $70,000 in taxes coming in, I as an elderly person am already an economic drain.

Again, this is a drain that a rich and compassionate society can well afford. But I continue to resist calling it a fair trade economically.

Just take the L, man.

Intellectuals: Credentialed in one field, and expect to be taken seriously about entirely different ones.

Well the silver lining to this rancid tripe is that it provides a complete and convincing refutation of the premise and arguments of Garrett Jones' 10% Less Democracy. Here we have an expert bubble regurgitating WHO talking points with blue sky abandon and not a shred of evidence of critical thought. Completely impractical and wholly oblivious to less costly and invasive alternatives, these geniuses give barely a glancing nod to the nursing home exposure crisis which is at the heart of the threat. Instead they whip themselves into religious fervor over an approach that is supported by at best anecdotal evidence and which in all probability would wind up increasing exposure. No role for cheap thermometer checks.
No support for practical prevention interventions like improved air filtration and circulation. Rather than targeting New York and Detroit and other critical locations, they insist upon a national approach. And they are a day late and a dollar short when it comes to fitting the response to the disease, other experts are already questioning track and trace: https://www.thetimes.co.uk/article/coronavirus-in-scotland-doubts-over-test-trace-and-isolate-approach-zcqvxrhh9

Thankfully we will survive this pandemic inspire of the experts because the vast majority of irrational and ignorant have each individually more common sense than the complex list of authors and contributors to this hot mess.

Prediction: Steve Sailer's practical recommendation to buy a pulse odometer will save more lives than a new track and trace program. https://www.unz.com/isteve/buy-a-pulse-oximeter/

The question regarding the inactivation of the virus on the swab before transport has been answered.
https://www.biorxiv.org/content/10.1101/2020.04.11.036855v2

Note that the relatively low temperature of 140ºF (60ºC) for 30 minutes is all that is required to achieve a 99.999% reduction in virus activity while keeping the RNA intact for analysis. Stronger treatments can further add to the deactivation, but such further reduction is irrelevant to personal safety.

For overall resilience relative to this virus, individuals and businesses need to operate with social and behavioral changes which will result in a reproductive rate for the virus (Re) creating less than one new case per case (Re < 1.0). Decreasing contact between people (lockdowns) will decrease Re but will clobber the economy. Decreasing the probability of virus transfer by using protective equipment (PPE), essentially making efforts to create an effective bubble around yourself will also decrease Re with less economic effect.

Citizens can assemble their own personal protective equipment (PPE) to limit virus transfer and can reuse their external garments, masks, gloves and shoes by the simple expedient of heat treating the items in ovens, and/or dryers at 60ºC (140ºF) for 30 minutes at home. This heat treatment, just like the swabs above, inactivates the virus and enables reuse. Decreasing the probability of transfer by 80 to 90% will make the virus go extinct in the population.

For detail on citizen PPE and protecting yourself and your business, I refer you to::

https://www.dropbox.com/s/lvmhxl4nyybprsi/Protection%20in%20the%20Covid-19%20era%20V4.pdf?dl=0

Do they suggest manual contact tracing with >100,000 people working on it? Really? in 2020?

Even if they can implement this manual contact tracing, how efficient will it be? Do you remember all people you have been in close proximity to for a recent 3 weeks? And this is even assuming that people will not lie about their contacts...

Totally agree. They probably can't have contact frequency and transfer probability the same as before and control it with testing/contract tracing in a democracy. We need to decrease the infection probability from contacts by training people on how to protect themselves by using and sanitizing protection equipment like masks, gloves and outer garments that can all be sanitized for this virus by heating in an oven or dryer.

https://www.dropbox.com/s/lvmhxl4nyybprsi/Protection%20in%20the%20Covid-19%20era%20V4.pdf?dl=0

The surge in cases in Singapore suggests that this type of approach has little chance of success. Whether we like it or not, the virus is ultimately going to spread to a large fraction of the population, the vast majority of whom are at low risk. All effort should instead be concentrated at isolating the most vulnerable subpopulations. So far we’ve done an absolutely terrible job of it, not because we didn’t know, but because we didn’t care enough to even try, NYS being a good example where infected nursing home residents have not been isolated.

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