May 13, 2020
pandemic  coronavirus  covid19  questions 

Pandemic Questions

This pandemic has been awful for all the obvious reasons. One less-obvious reason is that there is a lot of data we’ll need in order to beat it, but most of that data is unknown, either because

a) it’s considered unethical to do a study,

b) it’s not safe to conduct a study,

c) it’s not feasible to do a study given how large the sample group would have to be in order to be confident in the result,

d) it takes time to conduct a study so we’ll just have to wait even if we started all the relevant data-gathering right now,

e) we don’t agree about the importance of the relevant questions, so we don’t even conduct the right studies, or

f) we don’t know what studies to perform,

or

g) we know what questions to ask, but not how to design a study that will answer them

Here I list out all the questions I have about the pandemic that I could think of in the past few days. I expect it will be interesting to revisit this list in 1/5/10 years and see if I was even thinking about the right things. If it’s useful to others, great! If not, that’s fine too, it’s more of a personal brainstorming exercise than anything else, and I may investigate some questions in later blog posts. I’ve organized the questions roughly by category. If there are categories not present, it’s either because I didn’t think of them, or I don’t think there are many interesting questions that haven’t already been asked and discussed elsewhere.

Note: Many of these questions have answers floating around, of greatly varying quality. Posting a question here does not mean that I haven’t read an answer, only that I think it’s interesting enough to include in this list, or that the answers I read were not sufficiently satisfying.

The virus itself

  • How many virus particles do infected people expel with each breath / cough / sneeze on average?
  • Does that number vary over the timeline of the disease?
  • Does that number vary based on age/gender/race/pre-existing conditions?
  • What does the term “infected” mean, precisely? Obviously, if you are symptomatic, you’re infected, but at what point do you go from uninfected to infected? When the first virus particle enters your body? When the first cell is entered and taken over by the virus? When your immune system is recruited to fight the virus? (not specific to this virus, but still relevant)
  • How many virus particles do you have to take in in order to be “infected”? E.g. if you inhale 50 particles and your body successfully kills the virus before it really starts to replicate, does that mean you were infected? Or does it mean that you fought it off and were not infected?
  • If you take in a bunch of virus particles and your body fights them off, does that guarantee that you now have the right antibodies? Or is it possible to kill the virus without creating antibodies?
  • What does it mean to “have the antibodies”? Is there a threshold number of antibodies produced in a blood sample that puts you on one side or the other? If so, how do we determine that threshold, and is it one of those long-standing-constants that everyone accepts as standard but no one really has a good justification for?
  • How long can your immune system “save” a given antibody?
  • When people talk about how long you stay immune to the virus, are they really saying “the virus mutates so quickly that your antibodies from the first infection no longer fight off later versions of the virus”, or is there a mechanism where you lose your ability to produce the same antibodies against the same virus, or a mechanism where the same antibodies against the same virus is somehow less effective?
  • How quickly does the virus mutate?
  • How often is a mutation behaviorally signficant? My assumption is that the vast majority of mutations are harmful/destructive to the virus’ efficacy, and only a small percentage would strengthen the virus on some axis.
  • Will the virus have seasonal effects, and if so, why?
  • Regardless of what term you use (“aerosolized”, “airborne”, whatever), how far can a viable virus particle travel from an infected person assuming there are no significant air currents? How much does that increase with the force of exhalation? (2x? 10x? 1000x?)
  • If a virus particle doesn’t fall to the ground and instead stays in the air, how long does it stay viable?
  • If, as some scientists say, the coronavirus does not stay in the air, but instead falls to the ground (unlike measles, which can stick around for hours and infect someone later), what is the biological reason for that difference? Are the particles different sizes/weights? Does it have to do with their chemical structure? Are they somehow expelled differently?
  • What effect does smoking have on infections? (apparently in Italy smokers are drastically under-represented in the sick population)
  • Why are diabetics more vulnerable?
  • Are the populations that are more likely to get infected the same populations that are more likely to die from the disease? Or are there some features that would make you more likely to get sick but not more likely to die, and vice versa?
  • What biological property does the virus have that causes its carriers to be asymptomatic and infectious for so long before symptom onset (that other similar viruses do not have)?
  • If sunlight kills the virus, how long does it take? How strong does the sunlight need to be - will it be more effective around the equator than the poles?
  • Does copper really kill viruses faster than other surfaces? If so, what is the mechanism behind it? (Articles such as these are not particularly helpful.)
  • If so, how much faster does a virus die on copper than on stainless steel?
  • If so, would it be effective to cover lots of public surfaces in copper tape? I bought a roll of it for ~$12 on Amazon; I bet organizations like, say, BART, could get giant bulk discounts and wrap the poles and handles inside of subway cars pretty effectively.
  • I want a model that estimates individual risk, not population spread. I want to say “I estimate that on my commute, I touch N# surfaces that other people touch frequently, and I share an enclosed space with X# of people for Y minutes. Given that Z% of the general population is infectious but not quarantined, what is my risk of exposure when commuting twice a day?” Does that type of model exist?
  • What is up with the mysterious illness that children who’ve recovered from COVID-19 are getting?
  • How many real cases have there been / are there / will there be relative to known cases?
  • Why haven’t we seen a bigger explosion of cases in third-world countries? It could be that governments are suppressing/underreporting the numbers, or that countries don’t have infrastructure in place to gather that data, but it seems like it’d be difficult to hide so many more deaths than usual. That’s assuming people who are dying seek medical treatment, though; if most sick people just stay home and die, it’ll take longer to detect. If there really aren’t that many cases, why not? What are they doing that we aren’t?

Social Distancing

  • What is the actual risk comparison of being outside near someone who’s sick vs being inside near someone who’s sick? Is it 10x safer? 100x safer? 1000x safer? I think this will matter a lot in the coming months as we try to give people guidance about how risky certain behaviors are.
  • Where did the “6 feet apart” (charmingly, a “hockey stick apart” in Canada) guidance come from, and how did it get adopted so quickly? Is it backed by any actual evidence that the virus doesn’t travel 6 feet? (My intuition here is that if we actually want to be safe from the virus, it should be a lot more than 6 feet indoors.)
  • Should we vary the recommended #feet apart based on risk factors?
  • Will it be possible to create a system whereby people can indicate the risk factor they’re comfortable with? E.g. if you see someone walking around with a red ribbon/hat/necktie/whatever, it means “I’m high risk, please stay extra far away”? Would this even be useful (assuming people actually pay attention to it)?
  • What obligations do you have to someone coming down the sidewalk toward you? Should you a) keep walking normally, b) move to the edge of the sidewalk as you pass by, c) go into the street, d) cross the street? I have seen all of these in my runs around the neighborhood, and there doesn’t seem to be much of a consensus.
  • It seems like we’re going to have a world where sharing space indoors will be a bad idea for a long time. Will we see businesses converting indoor space to outdoor space (esp in locations with good weather year-round)? Will we see lots of companies retrofitting their existing spaces to have more airflow from outdoors?
  • Will we see a significant number people move to the suburbs/more rural areas permanently?
  • Companies are popping up to help offices retrofit their open desk plans in order to let their employees go back to work. As far as I can tell, this is mostly from interior design and furniture companies who are being tasked with making a workplace safer. Is there any actual evidence that panes of cough glass and cubicles make a difference? It seems to me like the enclosed air circulation is the much bigger problem. #securitytheater

Masks and protection

  • The saga of whether masks are effective seems to be over, and the pro-mask camp has won. The common wisdom now is that wearing a mask doesn’t really protect you from getting sick, but protects others from you if you are sick. Is this true?
  • If wearing a mask is supposed to help prevent you from getting sick, shouldn’t that mean we should be encouraging people to wash their masks and be very careful when taking them off?
  • If masks are effective at preventing transmission either way, wouldn’t we be able to to detect a difference in the rate of transmission in countries that already had strong mask-wearing cultures? If we don’t see that, what’s the explanation?
  • If you are infectious and are expelling virus particles, what percentage of virus particles would be blocked by a tshirt covering your mouth? By a bandanna? By a cotton mask? By a mask with filters?
  • Most people I see are wearing simple cotton masks, and all of the restaurants and services that are still open (post office, grocery store, CVS) now require face coverings in order to enter. I also see people not really keeping away from each other as much when they’re wearing masks. Is there a measurable way to determine if the risk compensation behaviors people do when they wear masks outweighs the benefit of wearing the masks in the first place? #securitytheater
  • Is it easier to get infected through your nose/mouth than through your eyes? If eyes are a common vector, should people be wearing eye protection as well as nose/mouth protection? It might look silly, but wearing goggles or protective eye equipment could be easily effective.

The Economy

  • For a small, local business, how long will it take to get started again, assuming everyone involved is happy to go back to work? How interdependent are businesses? Will there be bottlenecks that mean it’s hard for anyone to go back to work even if there are a lot who want to? Will we need to wait for some critical mass of customers/providers/supplies to be back in action before things, like, work again?
  • How many businesses will shut down?
  • What sort of second-order effects will that have on communities, e.g. blight and stalled construction?
  • There are a lot of people who can’t pay rent/mortgages right now. It’s all well and good to say that landlords have to take the hit, but eventually someone up the chain owes money to the banks. What happens when banks stop getting loan payments - will that trigger recessions/depressions/runs on the banks? Are our federal tools for fighting this kind of thing powerful enough?

Tracing

  • It doens’t seem like America is really going to pull together any sort of national tracing program, but if they do, how will we handle the enormous privacy concerns?
  • Does contact tracing even work when people are asymptomatic for so long? Given how many people commute on public transit each day, it seems like a single infectious patient could easily create so many potential contacts that it wouldn’t be feasible to perform tracing like that manually.
  • If we do automated tracing (ignoring the privacy concerns mentioned above), how will we implement it with few false positives? I worry that if I have an app on my phone and I get a notification that I could have been exposed every day for two months, but never get sick, I’ll stop paying attention to the notices. Proposals like the partnership between Apple and Google (which use bluetooth to record who you’re near and for how long, but not the circumstances) seem especially vulnerable to this.

Elections

  • What will happen in the 2020 election?
  • Even if many states do agree to do voting by mail, will they be able to prepare logistically in time to do it right?
  • If we do vote by mail and Trump loses, will he use the new method as justification for contesting the results?
  • If we don’t vote by mail and Trump wins, will Democrats use that as justification for contesting the results?
  • What are the chances that we do not have a peacful turnover of power in the case that Trump loses?

Vaccines

  • There are a great many attempts to find a vaccine happening all at once (see this great illustrated Nature article for more information). How should we evaluate the different technologies in order to predict which ones will work the best? Are there reasons to think that any of the above vaccine technologies will be uniquely good at fighting the coronavirus (vs being generally promising as a vaccine design)?
  • Will there only be one vaccine, or could multiple companies get approval? Some of my colleagues’ impressions were that even though there’s nothing stopping there from being mutliple vaccines, in practice we’ll only get one, because of something something regulatory simplifications.
  • Will the company that develops the vaccine also be the company to manufacture the vaccine? If not, how will they coordinate together?
  • Will we be able to start faster human trials of vaccines (e.g. purposely infecting test subjects after being vaccinated) given the costs of waiting the normal amount of time?
  • Or will a set of biological ethicists say that there’s no way to speed up the trials ethically?
  • If we can speed the vaccine testing up, will that negatively affect the public’s trust in its efficacy?
  • If so, would that be bad enough that we should stick with the normal trusted methodologies anyway, even though they’re slower?
  • If we’re concerned about public trust in the vaccine, are there some things to speed up research that would be less likely to trigger public concern?
  • What will happen if a mass hysteria movement against the vaccine (from conspiracy theories, Trump (oops, oxymoron there), lack of understanding of testing protocols) takes hold? Will we see schools and companies requiring proof of vaccination before going back to school/work?
  • As someone who works in the biotech industry, my bias is that the vaccine will be safe, because the R&D&Manufacturing processes will be scrutinized more than any other vaccine in history. I realize that others hold the opposite view that there will be so much pressure to get a vaccine out that we’ll be willing to cut corners. Should I be adjusting more toward that view? If so, why? If not, why not?
  • How long will it take to manufacture, distribute, and administer the vaccine?
  • How many people need to be vaccinated before we have herd immunity?
  • How will we decide who gets the vaccine first? (In the movie Contagion, it was distributed based on birthdays to ensure fairness. This doesn’t seem bad, per se, but it does seem inefficient and sort of easy to game, if faking IDs is easy. Should we vaccinate at-risk people first? Health care workers? Anyone working in essential industries?)
  • Logistically, how will we manage such a large vaccination project?

Mostly speculative

  • Will we see an increase or decrease in the number of births/pregnancies during the pandemic? I could see it going either way - you might hold off having a kid because pregnancies are riskier now that going to a hospital is dangerous, now that money is scarcer and less reliable, or you might decide to have a kid earlier to take advantage of working from home when they’re young.
  • Will so many older people die that it significantly changes the demographics of any country?
  • What will we call this event in 50 years? If the majority of the damage is directly related to the virus, I could see it being called The Great Pandemic, or The Coronavirus Pandemic, or something like that. If, however, the majority of the damage is in the second- and third-order effects like economic collapse, food shortages, other biological consequences (e.g. increased death rates from existing conditions where patients either can’t or are unwilling to get care because of the pandemic, increase in other diseases because we’re not vaccinating kids enough while we wait for it to be safe to go back to the doctor, increased antibiotic resistance from all the antibiotics we’re using as a treatment for pandemic patients, etc), it might be called something else based on whatever the worst part is - The Second Great Depression, The 2020 Depression, The Antibiotic Collapse of 2020, etc.
  • How long will it be until I travel abroad again?
  • Will there ever be a point where I can’t get a domestic flight that I want to take?
  • How many people will die directly from the disease?
  • How many people will die indirectly from second-order effects of the pandemic?
  • How strong will the resurgences be in the coming years?
  • Will doctors’ offices keep up their willingness to treat remotely when this is done?
  • Will the government attempt to mitigate the unemployment by creating a new civic corps? (This has been a pet idea of mine for a while, and I think it could be put to great use, especially for outdoor labor if outdoor work is basically safe.) This could be great for the students who don’t want to do remote learning and for people who were recently laid off, and could give America a chance to fix its crumbling infrastructure and clean up pollution and litter.
  • Given that most non-COVID-19-related research is on hold right now, and given that some experiments that are being halted won’t be able to start up again immediately, what long-term effects will that have? E.g. if X thousand number of people in America die of cancer in a given year, and we discover a cure for cancer a year later than we would have without the pandemic, is it fair to say that the people who died of cancer in that extra year were also, in a sense, victims of the pandemic?
  • How will all of the people who’ve lost family members handle grieving for their dead, especially without traditional funerals?
  • Will Trump ever be held accountable for the federal government’s lack of response? Will we ever have a reasonable estimate for the number of people who died unnecessarily vs the number of people who would have died no matter what we did?
  • A lot of health care workers are getting sick and dying from COVID-19. We could have a shortage of HCWs when this is all done. Will that lead to a change in how we train medical professionals? Will we see “medical bootcamps” that train up workers in a short, intense period to perform the less-skilled medical labor and free up trained doctors and nurses to handle more difficult decisions and cases?