Flattening the Curve Revisited

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Flattening the Curve Revisited

Should all businesses reopen immediately if local healthcare facilities are not overwhelmed?
Definitely.
No way.
Maybe?
Hmm…I dunno.

 

 

On one hand (likely the right one), it makes sense that healthcare systems should be optimized to work near capacity during a pandemic. However, due to COVID concerns and stay-at-home orders, the number of patients engaging the healthcare industry are drastically down across the country. This is true in each of the 4 hospitals I work as an ER doctor at in Salt Lake City and Las Vegas. This phenomenon creates huge inefficiencies and large losses of revenue (healthcare spending accounts for almost 18% of the entire US GDP).

1918 Mortality Curves by City

The doom and gloom prediction of overrun hospitals were largely never realized. Doesn’t this mean we have successfully flattened the curve? This is proof we should immediately reopen our economy and ease social distancing…right?

But on the other hand (let’s call it my non-dominant hand), I am inclined to proceed with caution. I am drawn to the most useful example in recorded human history for possible insights. The second peaks of deaths experienced across many U.S. cities during the 1918 pandemic give me pause.

What are the consequences of ‘unflattening’ the curve and allowing the virus to again begin to infect at increasing rates. Well, we don’t really know. We are still in the midst of this. And much uncertainty remains.

Were there possibly other reasons that we flattened the curve in the first place?

 

WHY DID WE FLATTEN THE CURVE ANWAYS?

We were incessantly told that we must flatten the curve to decrease the large burden a massive spike in cases would pose on any local healthcare system. We must spread the total number of cases over increased periods of time they said. But in my mind there are two other very important reasons to flatten the curve. Both seem to get much less attention, but are just as critical to achieving a successful response.

(Again, ‘flattening the curve’ refers to a concept in epidemiology in which the total number of cases of a disease is spread out over a larger period of time. Think back to circa early March 2020. You remember this figure, yah?)

Flattening the Curve

 

1. Preventing a scenario in which healthcare systems are overwhelmed

This will theoretically save many lives as the system will clearly perform optimally when not overwhelmed. I believe the mass disaster scenarios experienced by Italy and NYC (and their subsequent incredibly high mortality rates) prove these predictions to be true. Our first priority must be prevention of similar future outbreaks.

 

2. Allowing time for clinicians and researches to learn how to treat & prevent disease

Much has been discussed about development of vaccinations in this domain, but it has been fascinating for me as a physician treating the illness known as COVID-19 to observe the rapid changes in our treatment strategy in such a short time. Since I first began learning about COVID-19 less than 2 months ago, much has changed and in some cases radically been reversed. The optimal approach for fluid management, oxygenation, ventilation and other novel treatments have drastically changed. And outcomes are improving.

As one example, initial guidance was to intubate early. We were told any patient that required more than 6L nasal cannula should be immediately intubated and placed on a ventilator. Fast forward one short month. Now expert consensus and increasing medical literature is encouraging delaying intubation as long as possible and permitting levels of hypoxia that would never previously have been tolerated in a non-ventilated patient. Similarly, fluid management has changed considerably for these patients. COVID-19 is a very unique disease, unlike anything I have seen before. It requires novel approach by well-informed clinicians. There is no conspiracy. This is science in motion. And we are all better for it. Morbidity and mortality for hospitalized patients continue to improve. You are more likely to survive COVID-19 yesterday than 3 weeks ago. You are better off getting COVID-19 today than yesterday. We are learning. Pivoting. Adapting. Lives are being saved.

 

3. Aggressive social distancing and quarantines actually suppress and eradicate virus.

Let’s assume the incubation and viral shedding period combined for SARS-CoV-2 really is less than 4 weeks as currently advertised. In a perfectly closed system in which all travel is banned and all members of a society are forced to stay in their homes and not interact for a full month, upon reopening the doors there will literally be no more virus. The virus at this hypothetical time has ceased to replicate, shed, infect. Disease has locally been fully eradicated. Hypothetical high fives and cheers.  Although reopening travel will inevitably return the virus to these populations; the new baseline combined with improved testing, case/contact tracing, and more effective treatments should lead to a much lower mortality rate. Again, lives would likely be saved.

Clearly, this perfectly closed system is not feasible in most countries. New Zealand has taken this approach and seems to have been largely successful in achieving temporary eradication. South Korea is another shining example of how to implement a strategy in the real world that has rapidly transformed an outbreak that at one time was the largest outside of China to one in which there are nearly ZERO new daily cases.

 

LIVES LOST NOW, LATER, OR NEVER?

I often hear many confidently state that the same amount of lives will be lost regardless of when individuals become infected. Are we just kicking the can by flattening the curve? Delaying the inevitable? This will likely be true for some (possibly even for many) who suffer from significant medical co-morbidities or inflated biologic age. But, is it true that the ‘area under the curve’ will necessarily be the same irrespective of how long the x-axis is allowed to run to the right? The more I’ve considered this question, the more I am inclined to think that the policies we have implemented (albeit imperfectly) not only flatten the curve but also decrease the area under the curve. This would mean we are preventing COVID-19 deaths that will never occur.

Which 1918 city would you want to live in?

As each city, state and country begins to warily reopen, much will be learned from the variety of approaches taken. Some will fare better than others. Sweden may have taught the world a useful alternative middle way that could be replicated in similar societies. However, the unique properties of this virus dictate that decisions made today will not be realized for 2-3 weeks from now. That’s the most terrifying aspect in my mind. Another massive outbreak (or multiple simultaneous outbreaks in just a few large municipalities) could lead to chaos with even larger economic consequences. Each community will only get one chance to reopen and return (or not fully return) to pre-pandemic lifestyles.

Clearly, financial security deeply affects human prosperity. This should not be underemphasized. And obviously physical health is inherently tied to human flourishing as well. In the case of a pandemic from a contagious invisible microbe, these two aspects of human flourishing inherently come into constant conflict. Of course, we need to reopen. But there are clearly better and worse ways to do so. I hope, for the sake of many lives, we don’t mess it up. Would you rather be residing in 1918 St Louis or Philadelphia?

 

“He that can have patience can have what he will.”
~ Benjamin Franklin