Flatten the Curve: We Still Can Do Better...Hopefully

Early containment and delay in the US and many other countries around the world appears to have failed. That doesn’t mean it’s the end of the world. What it does mean, is it’s time to accept that we are standing on an exponential curve. It’s not insane to set reasonable goals and implement logical measures right now. But the costs of stronger measures that we might have to implement will get higher.

It also means that individuals, communities, and private sector leaders shouldn’t just wait on key public officials and governmental decision-makers to start having epiphanies about the benefits of science and coherent thinking. We are all decision-makers. So let’s make some good decisions.

We still can push-out and/or bend the sudden upward shape of the exponential curve downward upon which we are standing. And we are standing on one. We’ve been in the zone of complacency. This is a numbers game – even small reductions today can push-out and bend the curve down.

We need better visuals and messages of the different but interrelated impacts of large outbreaks. It’s not only just a matter of people getting sick. That’s obviously a huge part, but there are other connected chains-of-events in play to keep in mind.

There are other ‘non-health’ considerations that need to be taken into account that might not be getting attention. Whatever course the current outbreak takes, I think it makes sense to try to paint a high-level picture of how different moving parts work with, or against, each other.

I’m not a virologist, epidemiologist, or other expert in this field. I am a registered nurse, but I haven’t been bedside in a long time. There are way smarter people with ideas on how to properly contain and delay the growth of infections along an exponential curve. Keep that in mind. Anyway, here goes:

Viruses like SARS-COV-2 force us to realize how inter-related seemingly independent systems and components in the world can be. A contagious illness in China might have something to do with a local economy in America.

When thinking about whether or not we should pay attention to an outbreak, we need to think about more than just its effects on an individual person. There’s a much bigger picture to a system of cogs we wrongly think don’t work with each other.

If the worst of an outbreak is to be avoided or mitigated, it’s a good exercise to identify over-arching goals to guide the best steps to take, not just how bad a pathogen might make us feel (or even if it kills us). There’s much more.

In short, outbreaks require thinking in terms of cycles, systems, and feedback loops.

So, let’s see what’s needed to shift the Covid curve as far to the right and downward as much as possible.

Here are 3 broad interrelated goals:

A) Contain/delay the spread of total infections (and ultimately reduce more dangerous mutations that might make a recurrence later down the road)

B) Avoid healthcare facility overload (especially critical care units). One of the complications of severe cases is Acute Respiratory Distress Syndrome (ARDS). There are limited ICUs in the United States, each with varying capacities and qualities-of-care. If the mass of critical cases reaches a threshold depending on R0 and critical case rate, hospital overload could rapidly result. See this thread with a good visual of the why early measures are critical.

C) Avoid/minimize economic disruption. Early proactive measures are generally far less expensive than later reactive measures.

This triad needs nimble balancing. The ABCs:

A: If early containment measures are too ‘expensive’ (draconian), economic impacts can lead to an even longer problem list, like:

• Decreased production/distribution (food, pharmaceuticals, equipment)
• Lower employment
• Slower capital flows
• Social disorder
• Intensified spread

A: If early containment measures are too ‘cheap’ or delayed or confusing or non-existent, our travel along the exponential curve can lead to continued spread. Which, in turn, eventually hits the economy. Nasty feedback loop.

A: That’s why timing is so critical. Early, reasonable, low-cost measures can save both lives and economies. There’s a practical mental place to live in between complacency and unjustified fear, which makes early interventions sane things to implement.

B: Healthcare system overload. While most infected people may experience mild/moderate symptoms, there is a varying rate of those who require critical care (mechanical ventilation, vasopressors, 1:1 or 2:1 nursing:patient care). ICUs are relatively few in number.

B: This is why the magnitude (mass) of total infection matters, not only its (variable) rate. It’s the rate – and ultimately size – of critical care cases that significantly matter. Even a low rate of infections requiring critical care can easily overload hospitals.

B. For example, assume critical care case rates of 1-3% among a community of 1,000 infected individuals. That’s 10-30 beds. A region with a total of 30 ICUs can be easily overrun, depending on census. Keep in mind: that’s just at *that* moment of time. But time keeps on flowing. Apply a larger mass of total infections, and you should be able to get the basic idea.

B. Facility overload isn’t limited to treatment of infected patients needing critical care. Also impacted: Pre/peri/postnatal care (safe delivery of new little humans) and all other important heatlh_care (e.g. chemotherapy, critical diagnostics, traumatic injury admissions, and on and on).

B: Once a critical mass of hospital overloads and reshuffling of overall censuses is reached, exhaustion of healthcare workers and depletion of resources (O2 tanks, mech vents, medications, gloves, masks, linens, antibiotics/virals, sanitation support, etc.) set in.

B: Hospital overload does not require an apocalypse, where tires are burning in the streets, bodies splayed all over the ground, and zombies finally getting their chance to jump out of the movies and into our homes.

B: It is crucial to avoid Healthcare facility and system overload. If critical care units are unable to absorb critical cases, the risk of further community spread increases. These patients need to be somewhere – at home, makeshift spots, or who knows where.

B: The risk of Healthcare worker infection also rises, further reducing absorption capacity, in turn ramping up spread. Who replaces sick healthcare workers? Where do they get treatment?

B: Hospital overloading may not be foremost on the minds of the general population and key decision-makers, but it’s an endpoint to avoid as much as possible. It’s another reason to implement sensible containment/delay measures *early*.

C: Economic consequences and considerations. Economies have everything to do with individual and public health. Production and distribution of (vital) goods and services, stable employment of labor, and adequate capital flows ultimately support physical, mental, and social health.

C: Containment/delay measures have varying economic costs and consequences. Early measures are substantially less expensive than late measures. (This is where policy deciders often miscalculate.)

C: What are the high costs of *late* containment measures?

• Large-scale quarantines
• Slowdowns, disruptions, or shutdowns of (in worsening cases):
• Factories
• Power plants
• Sewage treatment facilities
• Garbage collection
• Capital markets

C: Low-cost early containment/delay measures include:

Work-from-home. If employees can do all their work (or critical work) remotely, it makes sense to keep employee working from home. Employers should shift as much work from in-office to remote as quickly as possible. Kind of a no-brainer. Although…

C: …work-from-home isn’t always a functional option for all workers and employers. Living paycheck to paycheck limits employees’ capacity to stay home without being able to perform duties. Indeed: economies have everything to do with health.

C: Some more low-cost early containment measures.

• Hand-washing: proper technique, routine, and protocols.
• Avoiding face-contact (mouth, nose, eyes) - easier said than done!
• Social activity: reduce travel/meetings
• Wiping of surfaces
• Hydration (a dry mouth can invite infiltration into airways).

C: Low/medium-cost containment/delay measures include cancelation/delay of mass gatherings and in person meetings. But the cost of these cancelations can have big payoffs for the economy and public health, and go a long way to smoothing and pushing out the curve.

C: Serious, intelligent consideration of air travel (domestic and international). Keeping in mind the nimble balancing act of the triad, this is a tough one! Staggering closings, criterion-setting, boosting airport monitoring/triaging could be intermediary steps before full shutdown.

C: School systems should already have had backup procedures in place (tele-education). Again, there are economic consequences to school closures, but we’re up against the high costs of uncontrolled viral spread. At a minimum, schools should consider cancelling non-critical activities and diligently implement and enforce proper hygiene practices. There’s a smart way to do this.

C: There are other strategies and measures and you can read more here: https://www.cdc.gov/flu/pandemic-resources/pdf/community_mitigation-sm.pdf

Healthcare Communication. Public messages from healthcare leaders, public health officials, and private sectors need to be straightforward, easily digestible, and free of fallacies (e.g. equating *absence of evidence* with *evidence of absence*).

Appallingly, even some authoritative sources have made fallacious (and weird) pronouncements. Healthcare communicators should triple-check their messages (and consult with critical thinkers with relevant knowledge/experience). Words like “never”, “always”, “should”, “shouldn’t”, “can’t”, and other unfounded absolutisms, are yellow/red flags to slow down and apply further critical thought.

Officials and pundits who make comments such as “research has shown X to be useless” should be held to account to cite specific research and explain exactly what context they have in their minds. If they’re winging it, then their credibility should be questioned.

Information requires proper context and framing. Yes, bad information is…bad. But even accurate information can still be misinformation if it isn’t issued within proper contexts or framing. Generalizations from particulars can be false, even when the particulars are true.

The P-word. Very often, the first response of even capable interviewees on TV shows to the question “What should we do” is “First, don’t panic!”. But that’s not a helpful (first) response. In fact it isn’t even an answer to the question. The question wasn’t “What shouldn’t people do?”

There’s an ingrained myth that people can’t handle good information. The goal of dealing with threats of an outbreak isn’t to avoid panic – it’s to prevent or reduce the outbreak’s effects. Keep that the focus of mass communications.

People will not panic if you provide them with empowering, useful, and relevant information. When asked about what people might be able to do, eliminate “don’t panic” from your talking points. It’s a terrible habit, much like saying “uh” and “um” when fumbling for words.

As stated earlier, we are all decision-makers now. None of us will have the absolutely ‘true’ information. We aren’t g-ds, we’re all just humans. But it’s a numbers game. Even small reasonable steps can make big differences...especially in advance of continuing proliferation and progression along the curve.

If this current outbreak turns out to be a much smaller event than can be reasonably foreseen today, that’s great. It means when we have confirmation that we’re sufficiently past the curve, we will need a major re-assessment of how we prepare to prepare so that we are actually prepared to successfully take measures.

It is near Spring. Hopefully we can shift out and bend the viral curve downward. But viruses mutate. We still don’t know what the Fall may bring. We might get lucky now, but dangerous mutations might evolve by the Fall or during another season. Let’s get early containment right.

An illustration. Assume 100 cases on a given day, with cases doubling every week (R0=2.0), and a critical case rate of 1%. Without any measures, in 13 weeks we’d have over 800,000 total cases, over 8,000 critical cases. That’s over 8,000 needed units.

If in the above scenario, if we even implemented reasonable measures and reduced R0 by 0.3% to 1.7%, in 13 weeks we’d have just under 100,000 total cases and just under 1,000 critical cases. Early measures matter!

Depending on the varying capacities and capabilities of healthcare facilities across the United States, that 0.3% decrease in R0 could convert into an 8-fold reduction in cases. We could still be at war, but we’d be fighting with better chances.

We haven’t covered mortality and case fatality rates here. That’s because a primary purpose of this appeal is to redirect attention away from ‘doom-and-gloom’ in order to articulate the importance triad of the ABCs in a realistic and rounded conception of what outbreaks can do to the world. Getting a grasp of the the need to keep critical case admissions as low as possible - by keeping total infections as low as possible. That's one endpoint that requires attention.

As of today, we don’t have an established R0 for covid-19, nor do we yet have a firm handle on R0 or critical care and case fatality rates. Metrics like R0, critical case rates, case fatality rates, and mortality rates aren’t inherent, immutable numbers because they depend on different factors that vary across countries, regions, and local areas, such as:

• Individual and community behaviors
• Government and private sector decisions and actions (or lack thereof)
• Mutations
• Demographic variances
• Quality and capacity of healthcare facilities in different countries, regions, and local areas. 

In other words, reasonable goals and logical measures matter, especially when these metrics can vary. They can also change as descendant mutations evolve novel properties, further complicating late efforts and media coverage.

The United States should have started working on the ABC’s several weeks ago. It could have pushed-out the curve. Complaining (without specific and useful calls-to-action) at this point, however, probably won’t help right now. Put it this way: viruses don’t have ears.

Very smart people have already worked out the proper goals and measures for greatly reducing the spread and impacts of outbreaks. What to do isn’t as mysterious as why we don’t do what we know we can do.

There’s still room for further research and knowledge, but the onus is us to exert pressure on governments, NGOs, private sector leaders, and others in power and ensure that what they do works for us all.

We also need to not only fund and support researchers in this field, we also need to empower them to play much bigger roles in prevention initiatives – not just in planning, but in active, ongoing participation to keep decision-makers from making bad decisions and missing key targets.

We need to pay attention to slowing down the replication of these tiny but evolving machines that don’t at all care about our happiness. We can’t expect them to care about our politics or economies or children. That’s our job.

What’s outlined in here can still be implemented starting now. It’s been said that evolution via natural selection is ‘smarter’ than us. We might not be able to outsmart them, but we can do our best to contain their spread, curtail their mutations, and avoid/minimize their impacts.

Let’s hope this Spring’s Covid curve is relatively gentle on us. Regardless of what it becomes, the next curve might be even bigger.

Let’s prepare for the next curve with the resources to support pre-pandemic plans when it’s early. Vital resources (such as testing kits, equipment, infrastructure, food and fluid stores, and so on) should be produced, available and accessible BEFORE it’s past the early stages of pathogen proliferation.

I tried my best to avoid errors in my thinking here, but I’ve also tried my best to put what I hope are useful ideas into the ether. Anyway, be kind, be thoughtful, be alert. 

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(This is a repurposing of a post I published on March 5. This article with be updated as needed.)