## AirToAll: Another guest post by Steve Ebin

Scott’s foreword: Today I’m honored to host another guest post by friend-of-the-blog Steve Ebin, who not only published a beautiful essay here a month ago (the one that I titled “First it came from Wuhan”), but also posted an extremely informative timeline of what he understood when about the severity of the covid crisis, from early January until March 31st. By the latter date, Steve had quit his job, having made a hefty sum shorting airline stocks, and was devoting his full time to a new nonprofit to manufacture low-cost ventilators, called AirToAll. A couple weeks ago, Steve was kind enough to include me in one of AirToAll’s regular Zoom meetings; I learned more about pistons than I had in my entire previous life (admittedly, still not much). Which brings me to what Steve wants to talk about today: what he and others are doing and how you can help.

Without further ado, Steve’s guest post:

In my last essay on Coronavirus, I argued that Coronavirus will radically change society. In this blog post, I’d like to propose a structure for how we can organize to fight the virus. I will also make a call to action for readers of this blog to help a non-profit I co-founded, AirToAll, build safe, low-cost ventilators and other medical devices and distribute them across the world at scale.

There are four ways we can help fight coronavirus:

1. Reduce exposure to the virus. Examples: learn where the virus is through better testing; attempt to be where the virus isn’t through social distancing, quarantining, and other means.
2. Reduce the chance of exposure leading to infection. Examples: Wash your hands; avoid touching your face; wear personal protective equipment.
3. Reduce the chance of infection leading to serious illness. Examples: improve your aerobic and pulmonary health; make it more difficult for coronavirus’s spike protein to bind to ACE-2 receptors; scale antibody therapies; consume adequate vitamin D; get more sleep; develop a vaccine.
4. Reduce the chance of serious illness leading to death. Examples: ramp up the production and distribution of certain drugs; develop better drugs; build more ventilators; help healthcare workers.

Obviously, not every example I listed is practical, advisable, or will work, and some options, like producing a vaccine, may be better solutions than others. But we must pursue all approaches.

I’ve been devoting my own time to pursuing the fourth approach, reducing the chance that the illness will lead to death. Specifically, along with Neil Thanedar, I co-founded AirToAll, a nonprofit that helps bring low-cost, reliable, and clinically tested ventilators to market. I know lots of groups are working on this problem, so I thought I’d talk about it briefly.

First, like many groups, we’re designing our own ventilators. Although designing ventilators and bringing them to market at scale poses unique challenges, particularly in an environment where supply chains are strained, this is much easier than it must have been to build iron lungs in the early part of the 20th century, when Zoom conferencing wasn’t yet invented. When it comes to the ventilators we’re producing, we’re focused on safety and clinical validation rather than speed to market. We are not the farthest along here, but we’ve made good progress.

Second, our nonprofit is helping other groups produce safe and reliable ventilators by doing direct consultations with them and also by producing whitepapers to help them think through the issues at hand (h/t to Harvey Hawes, Abdullah Saleh, and our friends at ICChange).

Third, we’re working to increase the manufacturing capacity for currently approved ventilators.

The current shortage of ventilators is a symptom of a greater underlying problem: namely, the world is not good at recognizing healthcare crises early and responding to them quickly. While our nonprofit helps bring more ventilators to market, we are also trying to solve this greater underlying problem. I look at our work in ventilator-land as a first step towards our ultimate goal of making medical devices cheaper and more available through an open-source nonprofit model.

I am writing this post as a call to action to you, dear Shtetl-Optimized reader, to get involved.

You don’t have to be an engineer, pulmonologist, virologist, or epidemiologist to help us, although those skillsets are of course helpful and if you are we’d love to have you. If you have experience in data science and modeling, supply chain and manufacturing, public health, finance, operations, community management, or anything else a rapidly scaling organization needs, you can help us too.

We are a group of 700+ volunteers and growing rapidly. If you’d like to help, we’d love to have you. If you might be interested in volunteering, click here. Donors click here. Everyone else, please email me at steven@airtoall.org and include a clear subject line so I can direct you to the right person.

### 26 Responses to “AirToAll: Another guest post by Steve Ebin”

1. Tamás V Says:

[…] having made a hefty sum shorting airline stocks

I wish you hadn’t said that. Brrrr. Sorry, that’s my opinion. (Don’t get me wrong, I’m not jealous, not at all.)

2. Scott Says:

Tamás #1: I wish I’d done the same. But even if I’d been knowledgeable and confident enough to do it, there still would’ve been the issue of the rest of my family!

3. James Cross Says:

I think maybe speeding up the pace on vaccine development in the best option. I know some are talking about testing it by exposing vaccinated volunteers to the live virus. Assuming there is informed consent, I don’t think I would be opposed to that. What do you think?

I think there should maybe be a number 5 relating to mitigating the economic impact. Of course, government needs to be involved a lot with that but there may be room for private solutions – expansion of food panties, expanding abilities for people to work or go to school from home (maybe not a problem for readers of this blog but a big issue for economically disadvantaged), other innovative ideas.

For my part, I managed to get enrolled in Phase 1 vaccine trial and received the first of two vaccinations yesterday.

4. sf Says:

This article suggests that use of pulse oximeters could finesse a lot of the testing problems and pre-empt much of the need for ventilators, which sounds fantastic, though as it stands the evidence looks convincing but remains anecdotal – it’s not a scientific study. It would be good if someone with knowledge of the subject could evaluate these claims or provide criticism.

https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html

5. sf Says:

Here is something I just found, but which came out early April, and that seems to contradict the NYT piece:

https://qz.com/1832464/pulse-oximeters-for-coronavirus-unnecessary-but-selling-strong/

So the jury is still out on this one. It doesn’t kill off the hope that pulse-oximeters could help a lot, but might help put it in perspective. In any case, just the possibility that some experts out there may have something so simple and practical but that hasn’t gotten the attention it deserves yet is both encouraging and astounding.

6. Mark Bennet Says:

“But we must pursue all approaches” – this is not necessarily true if resources are finite. The problem of allocation of limited resources against an uncertain threat is a challenging one.

There are issues of delivery pipelines also and the practical constraints on implementation. Issues of capacity include – if we can’t do everything now, but can do everything in time, how is the response best sequenced? And the reallocation of resource too – how can we best deploy people and their capabilities against the challenges of this new world?

7. Bill Says:

This has been all over the news lately that ventilators should not be used for covid19:

https://www.dailymail.co.uk/news/article-8230775/Is-proof-live-saving-ventilators-actually-deathtraps.html

I know this is dailymail, but read the article, which cites many expert sources. And googling will give you similar articles in many other news outlets. There is also this article in NYT today with similar information:

https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html?action=click&module=Opinion&pgtype=Homepage

Basically, the idea is that covid19 is nothing like regular pneumonia and ventilators should not be used in this case. Instead, people should keep track of their oxygen levels early on and use oxygen masks instead of ventilators.

8. Bill Says:

@sf #5: That Quartz article does not contradict NYT article, it just ignores the fact explained in NYT article that covid pneumonia is very different from regular one. It blocks oxygen while allowing CO2 to clear from the lungs, so people don’t notice low oxygen level as they normally would.

9. Bill Says:

https://www.nytimes.com/interactive/2020/04/21/world/coronavirus-missing-deaths.html?action=click&module=Top%20Stories&pgtype=Homepage

New York has 298% deaths above normal in the last month, while Sweden has 12% more deaths, and other places have typically about 30-50% more deaths. Perhaps, one reason for this is that ventilators have been used much more frequently in NYC than elsewhere.

Also watch a couple of minutes of this video starting at 19:35: https://youtu.be/H2E1t3yMXgE?t=1175

10. Filip Says:

A new research is showing that hydroxychoroquine, Trump’s favourite COVID-19 drug, actually increases mortality rate in serious cases.
https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v1
Note: sample size is small and I personally think this malaria drug wasn’t a bad idea (it’s far from being one of Trump’s worst mistakes).

11. sf Says:

@Bill #8

The qz article preceded the one in NYT, and it’s true that the CO2 factor can rebut some of the arguments in the former, but not everything there. Here are some excerpts that are left standing:

“Not all Covid-19 patients see their blood oxygen levels dip to dangerously low levels, if at all. Two … who tested positive for Covid-19 were studied by doctors … Neither had a fever or shortness of breath. Both had oxygen saturation levels of 95%, which is considered on the low end of normal.”

“It’s not unusual for oxygen saturation to stay normal or close to normal, and then drop suddenly. As a result, a normal oxygen saturation can be falsely reassuring,” Admon wrote to Quartz.

Also they are sceptical about the accuracy of the devices. This also shows that the pulse oximeters issue was making the rounds before the Levitan article, something that wasn’t made clear there.

But the real issue is whether it could help in some probabilistic sense. Even if its not a full solution, anything that puts a dent in R0 can play a useful role This is something to be optimistic about.

The articles you linked to on ventilators seem to miss the point: its not the absolute survival rate for ventilator treatment that matters, (20 or 30% < 50%, so what?) but where it stands compared to lack of treatment, or alternatives. No such figures are given to compare to. These are IC patients who are sure to die without something drastic to help them. The CPAP has been discussed a lot, but it's just a weak version of the ventilator which is usually inadequate, and the other dailymail link alternatives might help, but hard to know yet.

12. Deepa Says:

Regarding the different death rates (due to covid19) in different parts of the world, I’ve been reading that that could be because there are different strains of this virus affecting different places. Some strains are more pathogenic than others.

I have also been reading that ventilators seem, unexpectedly, not to help very much with this novel virus. It might be that the studies claiming that are faulty.

Best wishes to Mr. Ebin!

13. Deepa Says:

On treatment of Covid19 patients with hydrochloroquin (HCQ):

In Singapore as well as India (and possibly many other countries), it is routinely prescribed to Covid patients, even if it is early (early in the virus running its course).

I have spoken to 3 doctors in depth about this. Two in India, one in Singapore. They are very comfortable with this drug in India (unlike in the U.S) because it is used often in India to treat patients with malaria. The risks and side-effects are very familiar to the doctors there. Here are some interesting things I have learned from them.

1. They give a higher dose of the accompanying antibiotic Azithral/Zithromycin/ZPac there, i.e. 500 mg a day for 5 days. In America, it is 500 mg on day 1 followed by 250 mg a day. I think it is 5 days typically.
2. They also test for a deficiency of an enzyme called G6PD in India and Singapore, because that deficiency can cause anemia with HCQ.
3. They do a test (ECG? I am not sure) to rule out heart arrhythmias before prescribing the HCQ.

My impression is that this is routine Covid treatment in those countries now. Whether it is effective or not, I don’t think anyone there knows for sure.

Disclaimer : I am just a layperson. Take anything I have said with a generous pinch of salt!

14. Gerard Says:

@Deepak #12

“I have also been reading that ventilators seem, unexpectedly, not to help very much with this novel virus. It might be that the studies claiming that are faulty.”

Yes, it seems like almost every day we hear new, surprising information that often conflicts with previous claims. The more I hear about covid-19 the more convinced I am that we no one really understands it.

I suppose this along with growth curves that are still looking pretty exponential is far from reassuring to the anxiety prone or those who are overly attached to human existence.

15. fred Says:

I’m working on a mask that seals the entire face but doesn’t hide it, for 100% protection and better social interactions.
Something like:
https://i.pinimg.com/originals/23/52/8e/23528e8c9fb1a7f800c69c581f474cde.jpg

16. Gerard Says:

@Deepa

17. Deepa Says:

Comparing Denmark with Sweden seems interesting. Denmark has lockdowns, Sweden does not. This might be one of the most useful experiments to learn from.

I don’t see how opening up economies is being responsible, without massive testing and masks and other protective gear being widely available. You’d think the govt would get its act together on atleast this part of it. But we only hear bizarre comments like “We have the best and most powerful tests of all.”, from the president, whatever that means.

People have started making their own masks. Here is one site with good guidance : https://ragmask.com/

(No problem, on the name spelling).

18. Anonymous Says:

The emphasis on ventilators is probably the single thing the armchair covid19 epidimoligy twitter was uniformly vocal enough about to have actually reached through to decision makers and yet appears to have been largely misplaced because they turned out to be neither particularly life-saving with about 60%-85% fatality rate nor do they seem to be the mortality bottleneck being less scarce than ICU beds and the required support staff in todays hotspots.

19. Steve E Says:

@Mark Bennett #6 you wrote:

“But we must pursue all approaches” – this is not necessarily true if resources are finite. The problem of allocation of limited resources against an uncertain threat is a challenging one.

Back to reality: Is there a specific one of the four approaches I listed that you think we should ignore, because it would be too resource-heavy and not valuable enough if done, or is this simply an abstract argument?

Of course we live in a finite world with limited resources. And obviously I’m not saying we should stop agriculture to produce more vitamin D capsules.

I’m sorry I don’t have much sympathy for these “resources are limited” arguments. The cost of pursuing all four approaches I mention would probably be in the hundreds of billions at most. By contrast, the cost of *not* doing them is already, in these early days of the pandemic, in the tens of trillions. Here in the US we’re giving money to bailout cruise lines. There are plenty of resources to go around to fight the pandemic. There is widespread unemployment.

What we’re dealing with is a poor allocation of resources, not a lack of resources.

20. Steve E Says:

Bill #7, you wrote:

This has been all over the news lately that ventilators should not be used for covid19:

https://www.dailymail.co.uk/news/article-8230775/Is-proof-live-saving-ventilators-actually-deathtraps.html

I know this is dailymail, but read the article, which cites many expert sources. And googling will give you similar articles in many other news outlets. There is also this article in NYT today with similar information:

https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html?action=click&module=Opinion&pgtype=Homepage

Basically, the idea is that covid19 is nothing like regular pneumonia and ventilators should not be used in this case. Instead, people should keep track of their oxygen levels early on and use oxygen masks instead of ventilators.

What these articles have in common is that they use an unexpected datapoint, namely that up to 80% of COVID patients die on ventilators, to conclude that ventilators may not reduce the chance of death. This is like saying “47% of chemotherapy patients die after getting chemotherapy, therefore chemotherapy may not reduce the chance of death.”

The relevant question in oncology is “How does the 47% mortality rate of cancer patients receiving chemotherapy compare to the mortality of similar cancer patients not receiving chemotherapy?” and the relevant question with COVID is “How does the 80% mortality rate of COVID patients on ventilators compare to the mortality rate of similar COVID patients not put on ventilators?”

That question is unanswered today, but there’s more theoretical and empirical reasons to believe that ventilators help than that they hurt. The 80% mortality rate for patients put on ventilators is more likely to be due to a combination of the state of patients being put on ventilators and the known tenacity of this disease rather than the unknown (and theoretically unsound) idea that ventilators somehow accelerate acute respiratory distress syndrome.

Just as there are risks associated with getting chemotherapy, there are risks to being put on a ventilator. And just as doctors don’t always make the right decisions about who to put on chemotherapy, doctors also don’t always make the right decisions about who to put on ventilators. But these articles make it sound like doctors should simply maneuver patients’ bodies in different ways and the problem would be solved. Would that it were so.

There are certainly people who get chemotherapy who would be better off if they didn’t, and there are certainly people who get put on ventilators that would be better off if they didn’t. But in the same way that we want doctors to have access to chemotherapy meds, we also want doctors to have access to ventilators.

21. sf Says:

Just to update, some new links are given here relevant to the debate on ventilator use:

https://science.slashdot.org/story/20/04/22/2035254/researchers-to-doctors-stop-putting-covid-19-patients-on-invasive-ventilators

22. sf Says:

And a couple more…

https://www.yankodesign.com/2020/03/25/could-a-breathalyzer-detect-covid-19-northumbria-university-is-working-on-one-that-might/

23. dw Says:

More of the same, from slashdot:

Rei writes:
A paper recently published by The American Society of Tropical Medicine and Hygiene

https://www.ajtmh.org/content/journals/10.4269/ajtmh.20-0283

adds further support to recent CDC guidelines for minimizing the use of invasive ventilators.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/ventilators.html

As physicians had been voicing concern that doctors were being too eager to put patients on invasive ventilation and may be doing more harm than good,

https://www.statnews.com/2020/04/21/coronavirus-analysis-recommends-less-reliance-on-ventilators/

the investigators looked into outcomes of intubated patients vs. non-intubated patients experiencing hypoxia. Unlike with other forms of pneumonia, they found that COVID-19 patients were unusually damaged by invasive ventilation but also able to tolerate higher levels of anoxia — to the point that one doctor recalls having to tell patients to get off their cellphones so that they could be intubated. The recommendation is that guidelines be adjusted to discourage invasive ventilation unless a patient is physically struggling to breathe, rather than relying strictly on oxygen levels; otherwise, the use of non-invasive ventilation, such as CPAP and BiPAP, should be encouraged. When invasive ventilation is used, oxygen levels should be minimized in order to reduce the risk of damaging healthy tissue.

24. Gerard Says:

dw #23

“Unlike with other forms of pneumonia, they found that COVID-19 patients were unusually damaged by invasive ventilation but also able to tolerate higher levels of anoxia — to the point that one doctor recalls having to tell patients to get off their cellphones so that they could be intubated.”

If for some reason covid-19 impairs O2 absorption more than CO2 expulsion some of this makes sense. It’s high CO2 rather than low O2 that causes the subjective feelings of distress from suffocation. From what I’ve heard altitude sickness or even approaching death from O2 deprivation in an environment that does not impede CO2 evacuation can actually be a rather pleasant experience.

The part I don’t understand is why covid-19 patients would be able to physically tolerate objectively measured low blood O2 levels. Surely the O2 levels at which serious organ failure and/or permanent damage occur are well known objectively and aren’t merely a function of the patient’s subjective feelings ?

25. Aron G Says:

Hi Steve, thank you for your work. Following up on comment #4 are there any bottlenecks to the mass production and distribution of pulse oximeters and oxygen therapy concentrators for home use? Just in case early treatment of silent hypoxia turns out to be the magic bullet it might be worth thinking now about how to deploy it, just like Bill Gates will manufacture vaccines on a mass scale before knowing if they work.

I have mixed feelings about the Senators who shorted the stock market in January based on classified intelligence briefings. It was reprehensible of them to mostly keep the news to themselves, but relieving that at least some people somewhere in the deep state may have grasped the scale of what was to come.

26. Bruce Smith Says:

One of the hard parts about testing a vaccine is the possibility that it could protect you against SARS-CoV-2 (the COVID-19 virus) itself, but at the same time make you *more* susceptible to severe effects from a future mutated version of that virus. This is a known phenomenon for some viruses:

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