In the spring of 2020, when Covid-19 took its terrible toll in the US, three words offered a glimmer of hope: flattening the curve.
That phrase, and the diagrams that illustrate the concept, were everywhere in mid-March, just before the New York City eruption exploded. The city would see 10,000 cases and nearly 1,000 deaths every day through early April.
Covid-19 cases were on the rise and hospital systems risked being overwhelmed by patients with life-threatening symptoms. If hospitals ran out of beds or intensive care units, nurses or doctors, people would die unnecessarily – from Covid-19 and other causes. The way to prevent such a tragedy was to lock it down. A flattening of the epidemiological curve would keep the number of cases for our health system manageable.
"If you look at the curves of outbreaks, they go to big peaks and then they fall off," said Anthony Fauci, the nation's leading infectious disease expert, on March 10th. "We have to flatten that."
Vox wrote a statement on this idea. Barack Obama shared it with his tens of millions of Twitter followers. "Flatten the Curve" became a public health meme – there was even a Fauci bobblehead to contain it – but it was also an urgent call to action.
Christina Animashaun / Vox
The US has managed to flatten the curve – at least initially. Businesses closed and most states placed orders for stay at home. Later research found that these lockdown measures helped prevent tens of millions of cases of Covid-19.
But America did not use this window to improve its testing and traceability skills, and states quickly came under heavy pressure to relax their policies in order to reduce the economic cost of the shutdowns. The reopening started earlier than public health experts believed. The political will to impose new bans was gone when cases rose again.
At the end of 2020, with nearly 20 million Covid-19 cases and more than 340,000 deaths in the US, it was evident that trying to smooth the curve was not enough to end the pandemic. That doesn't mean it failed completely. Slowing the spread of Covid-19 should buy time to figure out what came next. But the US never did.
A medical worker puts on PPE at the start of his shift on April 16 at the Central Park Emergency Park in New York City. Mischa Friedman / Getty Images
America's political leaders have not set clear, common goals for managing the outbreak. And finally, the response from Covid-19 has become politicized, leading Americans to wear masks or social distancing instead of maintaining the solidarity necessary to eradicate a highly infectious virus.
The flattening of the curve became an abstraction with no real meaning.
"The value of 'flattening this curve' was related to that initial surge," said Albert Ko, who heads the epidemiology division at Yale School of Public Health, "and then it lost its value."
Flattening the curve worked – first
Flattening the curve was already a familiar concept in public health circles. However, the Covid-19 pandemic provided the first real opportunity to put it to the test.
"It was very popular for people at first when they saw the pictures of overcrowded hospitals," said Leana Wen, the former Baltimore City Health Commissioner. "The concept of 'flattening the curve' made sense when people realized the point was to make sure the hospitals didn't get too crowded."
"There are many millions of Americans who have made profound sacrifices and continue to do so today," she continued. "But it was applied inconsistently."
It may be difficult to remember now, but as of March, Americans largely agreed to accept the strategies needed to smooth the curve. The vast majority of states closed businesses and schools. Surveys showed that people were willing to take social distancing measures.
New York faced numerous challenges (the virus likely spread throughout the NYC area for weeks before it was discovered) and made its share of mistakes (sending infected patients back to nursing homes). However, the evidence of the strategy’s success lay in the turns. They were flat until the last winter flood.
Daily cases and hospitalizations in New York State. Covid Tracking Project
Several studies have found mitigation measures suppressed the spread of the virus and likely prevented millions of cases, and therefore many deaths. A study published in Health Affairs in May found that social distancing policies, including staying home and closing bars and restaurants, had blocked up to 35 million cases in the US by the end of April. Recent research published in Science concluded that closing schools and businesses, as well as limiting the size of private gatherings, significantly reduced its prevalence.
“NYC has flattened the curve. Other places have delayed it, ”William Hanage, an epidemiologist at Harvard University, told me. “But that should be an opportunity to improve testing and health care and prepare people for the long haul. You know that didn't happen. "
Experts created roadmaps for further action as soon as the original curve was flattened. A proposal from the American Enterprise Institute set specific thresholds for case numbers, hospital capacity and testing that should allow states to safely relax their lockdown measures once the virus has been adequately suppressed and the capacity of the health system expanded.
But the Trump administration never accepted these plans. Instead, the president often said that the cure (lockdowns) couldn't be worse than the disease (Covid-19). The White House eventually picked the message that the US must learn to live with the virus.
A reporter wearing a latex glove raises a hand to ask a question to President Donald Trump during a coronavirus briefing at the White House March 16. Win McNamee / Getty Images
America's failure to establish an effective test-trace isolate program is well documented. Some experts question whether contact tracing could have been as effective in a country like the US as it is in a country like South Korea, which is much smaller and has laws that allow government agencies to get into privacy in the name of public health to intervene. But everyone I spoke to agreed that the United States was not making the most of the time available from the flattening of the initial Covid-19 curve.
Instead, many U.S. states that had avoided the worst of Covid-19 in the spring saw the lack of an outbreak as a sign that they could press ahead with reopening. As soon as the curve was flat, the political will to keep it that way began to collapse.
America wasn't the only place it was difficult to figure out how to get out of its spring lockdown. Many European countries saw their own second waves in the summer. But the missed opportunity still set the course for the rest of the pandemic.
"We never really came up with a plan for a transition," said Caitlin Rivers, a senior scientist at the Johns Hopkins Center for Health Security who co-authored the AEI roadmap in March.
The Covid-19 pandemic revealed the limits of "flattening the curve".
In a way, the curve flattening worked as intended.
The hospitals were not – yet – overwhelmed, as they found themselves in a difficult situation in Lombardo, Italy, in the spring. But today, with cases and hospital stays still on the rise, US hospitals are warning that they are nearing a breaking point again.
The spring's slowdown in the spread of the disease also gave scientists an opportunity to learn more and more about the virus.
Among other things, they learned that people were most contagious before they showed symptoms. They found that the virus spreads mainly through breath droplets, not touch or surfaces. The increased risk of death for the elderly became more apparent. Researchers quickly began to figure out which treatments worked (placing patients on the prone position, administering remdesivir and dexamethasone) and which did not (Trump's preferred hydroxychloroquine).
With that information, the U.S. could have used the time it bought by flattening the curve to see if more targeted interventions would work better than lockdowns, as the science study suggested, and whether individual cities or counties are best at managing their own outbreaks could.
“Do we need strong interventions instead of calibrated? Do you need to have regional intervention to really make a bump? “Said Ko. "I think we were in that kind of limbo. Europe couldn't calibrate that. They had to go into lockdown."
The cost of this bug was not paid equally. The pandemic highlighted the many inequalities in American life, starting with who gets the virus and who dies from it. Black and Hispanic Americans are disproportionately affected by Covid-19, both in terms of health and the aftermath of the year's economic downturn.
If the curve didn't stay flattened, the most vulnerable were the people who had to go to work, live in intergenerational households, and have higher rates of chronic illness.
"I don't think we've ever properly understood how the news of the flattening of the curve and the challenges we face as a nation would affect the most vulnerable," said Utibe Essien, professor of medicine at the University of Pittsburgh . "The people who didn't have the same access to stay at home, mask themselves, who didn't have the same opportunities to do jobs, who didn't increase their exposure."
A cab driver wears a face mask and gloves as he drives through Times Square in New York City on March 26. Eduardo Munoz Alvarez / Getty Images
Otherwise, the flattening of the curve still failed to achieve its goal of gaining access to health care. While hospitals are not yet completely overwhelmed, some people are not getting the care they need. ProPublica reported that medical investigators in Houston saw an increase in the death toll in their homes over the summer. Some of these deaths were from Covid-19; Some were from heart attacks, strokes, and other illnesses. In any case, news of the rapid spread of the virus in the area may have deterred people from seeking medical help, with deadly consequences.
Throughout the year, with cases stubbornly high, doctors warned of the consequences of non-Covid-19 patients postponing treatment for chronic or emerging conditions. Studies have shown that visits to general practitioners and specialists have fallen sharply in spring and summer.
Health professionals fear that patients who may have had diabetes or heart disease may experience setbacks when they see a doctor for an initial diagnosis. It will take years to fully understand these long-term effects.
"It's like a lost year of nursing," said Essien, a practicing doctor.
The US has never turned away from flattening the curve
With 2020 drawing to a close and the US reporting 180,000 new cases and an average of more than 2,000 new deaths every day, there is no hope of flattening the curve.
Fortunately, vaccine development has been brisk and people are already being vaccinated against the coronavirus. But those in charge of public health still expect tens of thousands more deaths and comprehensive protection of the population in the coming months.
As a public health message, despite its initial success, "flattening the curve" has lost its power and America's public health leadership has failed to adjust to find a new message that would resonate with the people.
David Rehkopf, a social epidemiologist at Stanford University, drew a comparison with the anti-smoking campaign. A surgeon's general warning on cigarette packets had a quick and dramatic impact on smoking rates, but not everyone stopped smoking. Public health leaders have had to turn to new strategies to make further progress.
"With Covid-19, all of this has been cut to less than a year, not decades," he said. "Adapting quickly is difficult, but from previous public health campaigns we should have foreseen the need to do so."
When I reported on Melbourne, Australia's success in eradicating Covid-19, I learned that policy experts there feared that slogans like "flatten the curve" or "slow the spread" were too vague. Instead, the local health authorities developed detailed step-by-step instructions on how they could ultimately bring Covid 19 cases to zero.
Specific thresholds have been set: once we've hit X cases per day, we can reopen Y. Despite some controversy, this strategy was a success.
But in the U.S., under pressure from companies that had lost revenue for weeks and from anxious constituents who saw no immediate emergency in their daily lives, many states quickly began lifting their social distancing policies in the spring as soon as the curve closed seemed to flatten. Texas, which put a fairly toothless stay-at-home order in early April, picked it up a month later. By the end of June, the number of daily cases had increased by 600 percent.
There was not a single voice telling the public what mitigation measures were needed, why and what outcome we were working towards. (Andrew Cuomo, Governor of New York, who held daily briefings with hands-on presentations in the spring to convey the current state of the outbreak and next developments, was largely an exception among his colleagues.) The CDC was banned from the Trump administration of the whole Year over.
Instead, 330 million Americans had to do their own risk assessments – or they didn't.
Given the research showing that a small percentage of those infected are a very large part of the transmission, this was a recipe for disaster. And instead of taking proactive action when infection rates first spiked, which public health experts believe is most important given the pre-symptomatic spread of Covid-19 and its slow pregnancy, the governors seemed paralyzed and waiting to until the crisis hit them.
"The personal definition of Covid caution by every American is completely unique. Some have hidden at home for weeks, others travel the country to visit friends," Kumi Smith, epidemiologist at the University of Minnesota, told me via e- Mail. “While measures at the institutional level may seem extreme had they been implemented more consistently across the country for longer, we could possibly have achieved a sufficiently low community transmission, pending careful reopening in conjunction with other measures such as tracing and widespread measures Testing and isolating would have been possible. "
A waiter at Raku, an Asian restaurant in Bethesda, Maryland, wears a protective face mask as they serve customers outdoors amid the coronavirus pandemic on June 12. Sarah Silbiger / Getty Images
The paradoxical lesson from the flattening of the Covid-19 curve is that the concept has proven itself, but it may be more difficult to educate the public about such a strategy in the future.
Nobody denies the value of slowing down transmission to take pressure off the health system. But it had an expiration date as a motivational tool.
“We know it works. We've seen it over and over again in this pandemic, ”said Jen Kates, director of global health at the Kaiser Family Foundation. "This will be a standard part of pandemic preparation and response."
"An open question, however, will be to what extent the concept has been poisoned by the political discourse." She added. "How successfully can it be used in the future?"
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