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Flattening The Curve Is Still The Right Answer.

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Flattening the Curve Is Still the Right Answer.

Public health and economic growth are two sides of the same coin.

The COVID-19 trends in the United States are moving in the wrong direction. More than 4,200 deaths occurred during the week of July 5th, and the highest number of new infections in a single day—more than 66,000—was reported on July 10th.

“I skate to where the puck is going to be, not where it has been.”

As the numbers of cases, hospitalizations, and deaths surge to record levels in multiple epicenters, local and state officials are struggling with whether and how much to reverse the rollback of restrictions on individuals and businesses. For example, following a gradual reopening over about a month, on Monday, California Gov. Gavin Newsom announced the reintroduction of statewide restrictions that would again shut down bars, all indoor dining, family entertainment, zoos and museums following a surge in coronavirus cases. The governors of Florida, Texas, and Arizona, all now epicenters of infection, have also slowed or reversed reopening, but their actions have been tepid. Florida Governor Ron DeSantis is even insisting on opening schools in the face of record-high numbers of infections. 

These officials would do well to recall the observation of The Great One. No, not Dr. Tony Fauci of the National Institutes of Health—the other one, hockey legend Wayne Gretzky, who once explained, “I skate to where the puck is going to be, not where it has been.”

Anticipating what’s coming is important in confronting an infectious disease, especially one whose dynamics are what many infectious disease experts consider their worst nightmare. COVID-19 is highly infectious, has a lengthy incubation period (during which asymptomatic infected persons can unwittingly shed virus and infect other people), and causes serious, sometimes fatal illness.

Those unusual characteristics of the SARS-CoV-2 virus, which causes COVID-19, and the idiosyncrasies and spectrum of presentations of the illness—from pulmonary symptoms (including pneumonia and pulmonary fibrosis) to a range of non-respiratory manifestations, (including loss of sense of smell or taste, confusion and cognitive impairments, fainting, sudden muscle weakness or paralysis, seizures, ischemic strokes, kidney damage, and, rarely, a severe pediatric inflammatory syndrome) mean that we are on a steep learning curve.

The problem is: if we react too slowly to changing circumstances, we can fall off a metaphorical cliff.

There’s an old brain teaser that perfectly illustrates this point. Consider a pond of a certain size, on which there is a single lily pad. This particular species of lily pad reproduces and duplicates itself once a day, so that on day 2, you have two lily pads.  On day 3, you have four; on day 4, you have eight; and so on. Here’s the teaser: if it takes the lily pads 48 days to cover the pond completely, how long will it take for the pond to be covered halfway?

The answer? 47 days. In just 24 hours, between day 47 and day 48, the lily pads would double in size and overtake the pond. Moreover, on day 40, the pond would still appear to be relatively clear; just eight days from the pond being completely covered, you’d hardly know the lily pads were there.  

If the same thing happens with a virulent and highly contagious infectious agent, like the SARS-CoV-2 virus, you don’t know you’re in trouble until you wake up one morning to find that you’re overwhelmed. Like the lily pad example, the daily number of confirmed COVID-19 cases in the U.S. was 18,577 on June 15th—just three weeks later, on July 10th, the number had shot up to 66,281.

Dr. Anthony Fauci

Dr. Anthony Fauci

FLATTENING THE CURVE TO BEAT THE IMPENDING CLIFF

From early in the pandemic, the public health mantra worldwide has been: “flatten the curve.” That important concept, which was in vogue several months ago, seems largely forgotten today.

Source: University of Michigan

Source: University of Michigan

In the above graphic from the University of Michigan, the blue curve is the viral equivalent of the lily pads, suddenly covering the pond. It represents a large number of people (shown on the vertical axis) becoming infected over a short time (horizontal axis), and, in turn, overwhelming our health care system with people who need hospitalization, or even an Intensive Care Unit (ICU).

People won’t shop for non-essentials, fly, go to restaurants, theaters, and athletic events, or send their kids to school, when numbers of new cases are soaring.

If, however, political officials, individuals, and communities take steps to slow the virus’s spread, the cases of COVID-19 will stretch out across a more extended period, as depicted by the flatter, yellow curve. As long as the number of cases at any given time doesn’t bleed past the dotted line marking the capacity of our nation’s health care system, we’ll be able to accommodate everyone who is very sick.

Curve-flattening has fallen out of focus in recent months, in part because some political leaders reopened too aggressively and prematurely, basing policy on their constituents’ “pandemic fatigue,” instead of on the advice of epidemiologists and infectious disease experts.

But it’s still critical to avoid the pattern of the blue curve, not only to spare hospitals and ICUs—which are especially under stress in parts of Arizona, Florida, and Texas—but also so that we can continue the gradual reopening of the nation’s businesses and schools. Reopening relies on curve-flattening. As the NIH’s Dr. Tony Fauci says frequently, public health and economic considerations are not in opposition but are opposite sides of the same coin; we can’t fully restart and resume commerce until the pandemic is under some measure of control. People won’t shop for non-essentials, fly, go to restaurants, theaters, and athletic events, or send their kids to school, when numbers of new cases are soaring.

That means we need to start anticipating and stop playing catch-up—as the governors of Florida, Arizona, and Texas have been doing, relying on a combination of magical thinking, Happy Talk, and too-little-too-late remedies, instead of aggressive, evidence-based public health policies.  

Arizona Governor Doug Ducey, for instance, has offered no strategy for blunting the spike in COVID-19 cases other than to keep repeating that there were enough hospital beds to treat those who fall ill. And yet, ICU beds and ventilators in use by suspected and confirmed COVID-19 patients in Arizona both hit new records on July 12th and were under stress, according to data reported by hospitals to the state. 

On July 10th, a physicians group gathered outside Florida Governor DeSantis’s mansion in Tallahassee to urge him to issue an order mandating the use of face masks statewide, which arguably should have been done months ago. Masks have long been considered essential to slowing the spread of COVID-19, but, inexplicably, the Governor resisted. And only on July 10th did Texas Governor Greg Abbott finally mandate the wearing of face masks, and demand the prohibition of large gatherings and the closing of bars across the state.

Elected officials must heed Wayne Gretzky’s admonition and stay ahead of the coronavirus, in order to lower its rate of transmission. That’s the only way to slow the rise of new cases.

Evidence-based policies, such as requiring masks in public, prohibiting large indoor gatherings, and indoor dining at restaurants, are important. But as we’ve seen with California, even aggressive imposition of those kinds of strictures has not been sufficient—in large part because many people, especially younger ones, have failed to comply. As California allowed businesses and public places to reopen, bars, boardwalks, and beaches became crowded with large numbers of maskless patrons. It’s no wonder, then, that as of July 13th, hospitals in the state reported a 27.8% increase in hospitalized patients over the previous 14 days and a 19.9% increase in ICU patients over that same period. In fact, as a result of noncompliance, many local governments in the Golden State have had to coordinate with law enforcement agencies to issue citations and explore civil alternatives through code enforcement, environmental health, or other local government personnel.

Of course, the need for heightened consequences for noncompliance is unfortunate, but it will help to re-flatten the curve. That will spread out the demands on hospitals, which must have sufficient space, supplies, and healthy staff to care for all those who need hospital-level care—whether for COVID-19, a stroke, trauma, emergency surgery, or childbirth. It’s strong, but necessary, medicine—which possibly could have been avoided with more intense efforts to get the public to comply with wearing masks, social distancing, and frequent hand-washing. 

If politicians properly understood their role in flattening the curve, they wouldn’t have to resort to policing and ticketing. They would instead launch a tsunami of public service announcements from all manner of dignitaries and celebrities, including prominent politicians, actors, rock stars, and athletes—maybe even The Great One himself—demonstrating how we can anticipate instead of falling behind the curve.

That non-coercive strategy could be a winner.

Henry I. Miller, a physician and molecular biologist, was a Research Associate at the National Institutes of Health and the founding director of the FDA’s Office of Biotechnology. You can find him online or on Twitter at @henryimiller.

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