Flattening the Curve — from May 2020

Taylor Nichols, MD
5 min readOct 15, 2021

I want to address something that seems to have been lost in discussions of “flattening the curve” that I’m not sure the public generally understands given the otherwise simplified messaging. Flattening the curve doesn’t mean “defeating the virus.”’

The steepness of the curve represents the RATE of infections. Flattening the curve means decreasing the rate of infections, but not eliminate the virus or defeat the pandemic.

If the curve represents the RATE of infections, then the area under the curve represents the NUMBER of infections. Both curves have the same area, and flattening the curve will not eliminate the infection, but spread the number of infections out over a longer period of time.

In fact, flattening the curve will specifically mean prolonging the spread of the disease and the course of the pandemic over time. This may potentially mean continuing protective measures for even longer if we are able to keep the curve flattened by doing so.

That is to say that there will still be a massive amount of people infected with SARS-CoV-2, the name of the virus causing the COVID-19 pandemic. We will not completely eliminate the virus nor people dying from becoming infected.

What “flattening the curve” does do though is SAVE LIVES. How, you wonder? By preventing the potential deaths that would result from a rapid and dramatic rise in the number of people requiring hospital-based care and medical interventions, but NOT by eliminating the disease.

A huge turning point in the COVID-19 pandemic when we went from a “containment” strategy initially of trying to isolate cases. Containment means that you can potentially control and eliminate spread entirely. Think of the Ebola epidemics, as an example.

Once we switched to a “mitigation” strategy, that meant that we no longer had adequate control and could not (or were not going to try to) contain or eliminate the disease. The best approach we had remaining was to try to manage and slow the spread, so that we could provide treatment to folks who need it.

An important point to note is how significant a factor testing plays into these strategies. Containment strategies are impossible without an adequate supply of accurate tests. If you don’t know who has an infection, you cannot contain or control or eradicate the infection.

But adequate testing also plays an important role in mitigation strategies as well. South Korea is a perfect example of this: https://www.reuters.com/article/us-health-coronavirus-testing-specialrep/special-report-how-korea-trounced-u-s-in-race-to-test-people-for-coronavirus-idUSKBN2153BW?

With adequate testing, you can better identify and isolate infected individuals and slow or even eventually stop the spread. Without adequate testing, and unable to adequately identify infected individuals, the only way to prevent further spread is dramatic society wide measures.

Especially when the infection is coinciding with a particularly bad “flu season” and the disease of interest, infection with SARS-CoV-2, shares many of the exact same features or characteristics of an influenza virus infection in the vast majority of cases.

This is why “stay at home” or shelter-in-place orders are being announced for counties and even entire states, and why EVERYONE plays a critically important role in physically distancing from others and staying home unless absolutely necessary. https://time.com/5806477/what-is-shelter-in-place/

Remember social distancing doesn’t mean social isolation! Check in on your neighbors if you can from a distance. Call your family. FaceTime your friends. This is why I’ve preferred the term physical distancing, which is more accurate and creates less of a feeling of hopelessness.

If we had access to dramatically increased abilities to test the public, such as with the drive-in testing that South Korea was employing, we could have a much more rapid and focused response, and potentially lift such “stay at home” or shelter-in-place orders.

Yet, nearly every hospital or clinic cannot even test all patients with symptoms that could potentially be consistent with a mild case of SARS-CoV-2 infection. Colleagues in NY are only allowed to test patients who are being admitted to the hospital right now.

And worse, because we can’t test these patients, and because people can have very mild or even no significant symptoms and still carry the virus, health care workers can become sick themselves or become carriers of the virus without adequate protection even for mild cases.

PPE worn for any patient with respiratory complaints or possible COVID-like illness

This is why we have to use more personal protective equipment (PPE) when treating patients, and have developed a critical shortage across the country. Critical to the point of clinicians making their own equipment to protect themselves. https://www.businessinsider.com/doctors-frontlines-coronavirus-protective-gear-running-out-2020-3

If we become infected, we can become carriers and spread the virus to other health care workers or patients. If we become sick and unable to work, or die, there may not be enough clinicians to replace us. There is no emergency in a pandemic (a thread): https://twitter.com/amychomd/status/1240030939624939523

Credit to Aaron Mishler, a nurse, former Army Medic, and Ebola responder in West Africa in 2014–2015 who originally wrote this as a blog post based on his experience

I found article useful in explaining this point: https://www.washingtonpost.com/health/2020/03/19/coronavirus-projections-us/

While this circulated just over a week ago and, despite the rapid progression of this pandemic and the changing data as more information becomes available, this is still a long but incredibly worthwhile read: https://tomaspueyo.medium.com/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca

Also, the podcast The House of Pod recently did a 2 part series on COVID-19 and addressed this issue specifically in Episode 2 of their series with intensivist/pulmonologist Dr. Allison Freidenberg: https://podcasts.apple.com/us/podcast/episode-60-emergency-podcast-2-coronavirus/id1225096382?i=1000468581135

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Taylor Nichols, MD

Humanist. Emergency Medicine and AddictiEmergency + Addiction Medicine | Health policy and advocacy | Health tech and innovation