By Flattening The Curve We Are Flattening The World

The solution to halting the pandemic isn’t to wreck civilization

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I wish it need not have happened in my time,” said Frodo. “So do I,” said Gandalf, “and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.”

The neurosurgeon swept into the room where my wife had been waiting for twelve tension-filled hours.

“I have good news and bad news,” he announced.

“The good news is that I was able to remove most of his brain tumor.”

My wife sagged with relief. “What’s the bad news?” she asked.

“The bad news,” he said, “is that your husband died on the operating table.”

I’m not actually writing to you from beyond the grave. In truth, that neurosurgeon had only good news for my wife that March evening in Toronto.

The malignant growth that upended my life had shoved aside my brainstem and thrust its malignant tentacles deep into my brain. But it stood no chance in the face of my neurosurgeon’s skill and tenacity. He extricated the bulk of the unwelcome invader and left me largely intact, well-positioned to begin the long road to recovery.

He purposely left some residual tumor behind, wrapped around a key artery to my brain. Aggressively removing that piece might have ended my life-curing disease by killing the patient isn’t the wisest of strategies.

Thanks to the strategic efforts of that surgeon, I’m still here thirteen years later, living a full and productive life as a pediatric emergency physician and father of four children.

But today my life is once again in imminent peril. Not from the residual tumor (which I keep at bay with a daily dose of anti-cancer medication), but from CoVID-19, the lethal coronavirus that threatens to end the world as we know it.

As an immunocompromised physician working the front lines in the teeth of a pandemic, I’m at particular risk. On top of that, my wife is also a physician, an obstetrician also stationed at the front. The chance that this virus will take root in either myself or my wife is pretty high. The news from Italy, where already a dozen doctors in the trenches have succumbed to CoVID-19, isn’t comforting.

But our personal risk is not your concern. Nor is it my biggest concern: as doctors we signed up for this — it’s part of the job.

I’m far more concerned about our current pandemic strategy and the turbulent, destitute world we risk leaving behind for our children and grandchildren.

“Flattening the curve” has infected our vocabulary with the speed of the coronavirus itself. We (me included) bought into the notion that by decreasing the intensity of spread — by “aggressive social distancing”, by reducing the size of large gatherings, by limiting travel, by washing our hands obsessively, by closing schools and daycares and so on — we could significantly lessen the stress on our health care system.

All of these things are important — please don’t stop doing any of them.

But by themselves they won’t be much of a “cure”, as Tomas Pueyo argues convincingly in his excellent new essay: “Coronavirus: The Hammer and the Dance”. Simply flattening the curve will not stop this pandemic.

Our health care system is almost certain to collapse under a tsunami of sick and dying patients, regardless of whether we slow the intensity of spread or not. And many non-CoVID patients, starved of proper care as coronavirus patients suck up all the resources, will die as well.

Consider the scale of the problem in Canada alone. If the virus infects 30% of our population (the low end of estimates), that’s eleven million people. We can expect five percent of those infected to become critically ill: roughly 550,000 people will need intensive care beds over an 8 to 12-week period — and that’s at the LOW end.

Stack that number next to the 3200 intensive care beds (and 5000 ventilators) we have in our entire country. And it’s not as if those beds are currently sitting empty, silently anticipating the arrival of CoVID victims — they’re filled by patients with other critical illnesses.

We’ve made gargantuan efforts in recent weeks to ramp up our capacity in light of the viral freight train bearing down on us. But even if we double our capacity — or quintuple it — and magically restore to health and discharge all the current occupants of ICU beds, we will be hopelessly overwhelmed.

What is happening in Italy will soon happen here: doctors will be forced to choose — over and over again — who lives and who dies, which patient gets the ventilator and which patient does not.

And that’s going to happen whether we flatten the curve or not.

And in the process of flattening the curve we are flattening the world, wiping out financial markets, erasing jobs by the millions, vaporizing wealth, crumbling the foundations of our economy, creating civil unrest, and impoverishing the globe for decades to come.

We are, as it were, trying to cure the disease while killing the patient.

What, then, should we do?

Should we join the ranks of a public that is increasingly demoralized, confused, terrified, and hopeless — a public fatigued by constant bombardment with ghastly statistics, dire warnings and ghoulish death counts?

Should we throw up our hands in despair and surrender?

Should we open the schools and the daycares and the stadiums, ease all restrictions, and let the virus do what the virus will do?

Should we simply take the grim haircut to our population and rely on eventual development of “herd immunity” to protect us?

NO, I say. A resounding NO. A thousand times NO.

We must never surrender. We must fight with ferocity; but we must fight with intelligence.

Flattening the curve isn’t enough. We must level it, knock it to the ground — and then keep it there.

How do we do that? I’ll get to that in a moment — but first a few words about herd immunity.

Contrary to what many of us hoped, we may not be able to depend on substantial herd immunity to reliably protect us from CoVID-19 after this pandemic is over.

The development of effective herd immunity depends on infectious organisms’ genetic code remaining relatively stable. But this coronavirus isn’t stable — it’s actively mutating.

With every replication it has an opportunity to mindlessly change its code — and thanks to hundreds and hundreds of millions of hosts it’s getting billions of opportunities. And the more it changes, the less effective herd immunity will ultimately be.

A second version of CoVID-19, distinct from the Wuhan original, had already evolved before the virus took flight from China; new mutations are now besieging Europe, America, and undoubtedly elsewhere.

This is the phenomenon that requires scientists to collaborate on a new influenza vaccine every year. Influenza mutates, just as the coronavirus is doing, which is why the flu vaccine for the 2019/2020 flu season will offer scant protection against influenza variants that will dominate next year. Even with their best collective well-educated “guess”, scientists produce annual flu vaccines that provide only 40–70% protection, because the virus mindlessly mutates after the vaccine is launched.

That means that even if we are successful in eventually producing a vaccine against CoVID, it will need to be changed every year; and that like a flu vaccine, it would be unlikely to provide complete protection. CoVID-19 is ten to thirty times deadlier than the flu: imagine enduring its horrors year after year after year.

It needn’t come to that. It mustn’t come to that.

We must bring this pandemic to heel. The future of the world depends on it.

Simply slowing the spread of the virus will not suffice. We must stop it completely, or as near to that as is humanly possible.

Flattening the curve to mitigate the pandemic will not be enough: we will suffer a horrible defeat — the death toll will be enormous.

We can still beat this thing. But we must change our tactics.

In “Hammer and Dance” Tomas Pueyo maps the winning strategy — readily adaptable even to countries like the U.S. where the virus has spread unchecked for weeks.

Mitigation — slowing the virus by flattening the curve — must be distinguished from suppression. Suppression is stopping the virus in its tracks.

And it is suppression, rather than mitigation, that is key to victory.

It’s not complicated. But it requires collective will and strong, unbending leadership.

Please take 30 minutes to read through his “Hammer and Dance” essay for yourself. It may be the most important 30 minutes of your life.

In short, the strategy looks like this:

  1. Buy critical time by locking everything down. Stop the exponential spread of the virus TODAY. Otherwise we don’t stand a chance.
  2. Test, test, test. Quarantine and isolate.
  3. Slowly release the lockdown as people and communities are cleared.
  4. Keep testing — don’t let up.

We’re behind the eight-ball in Canada and in much of the world. We left our airports wide open for many weeks as infected people streamed in from around the world and contaminated our communities.

And we are seeing only the very tip of the iceberg. Most of the infectious cases are submerged: we don’t see them because we aren’t testing them.

My home province of Alberta is testing more than anywhere else in North America-300 tests per 100,000 citizens. But it’s a mere drop in the bucket. We need to test everyone, or as close to that as possible. And we need to retest them every week, for the foreseeable future.

We know from the example of Singapore and Taiwan that the ticket to successful containment is widespread community testing, relentless contact tracing, and rigidly enforced quarantine and isolation of positive cases. They stamped out the viral embers before they could burst into flame; their citizens now carry on with daily life with minimal disruption despite their proximity to China and early exposure to the virus.

We are not Taiwan or Singapore. The fires are openly burning. Patients are already dying in our hospitals. And we are severely constrained by a scarcity of swabs and a scarcity of testing ability.

But, again, it’s not too late.

In the Second World War the Allied war effort was constrained, at first, by a scarcity of equipment and a scarcity of firepower. But that didn’t last long. As millions of young soldiers went off to war, Allied countries retooled their factories and harnessed the energies of the hundreds of millions of motivated citizens to frenzied production of the helmets, boots, weapons, ammunition, and equipment those soldiers needed.

We must immediately pivot to a war footing.

We must lock everything down to buy time. We can’t have any more fires. We must close all non-essential businesses and mandate that all citizens shelter in place, with strict controls and with severe penalties for non-compliance; mobilize the military if needed for enforcement.

Police, firefighters, healthcare workers, farmers, grocers, pharmacists, utility workers, and the like must continue working at the levels we need.

We must immediately re-purpose our factories to massively increase our supply of diagnostic swabs and testing capacity, and to churn out face masks, ventilators, medical supplies and personnel to deal with the current crisis. Prime Minister Justin Trudeau’s announcement yesterday regarding retooling factories is a welcome and necessary start — but it’s only a start.

The stories emerging from the Italian front are horrific and heartrending as the viral crisis continues to rage in that country. But there are bright spots, even there. Health authorities in Vo, Italy, completely stopped the spread of disease in their city by testing and retesting all of its 3300 inhabitants, regardless of whether they were symptomatic or not; asymptomatic carriers were identified and quarantined before they could infect others and released only after they tested negative.

We can replicate the Vo experience here in Canada and worldwide. But we need to get smart, and we need to get serious.

It’s extremely important to emphasize that if we do this right — once we implement Pueyo’s “Hammer and Dance”, once we have universal, serial testing in place — complete lockdown need not last for long: perhaps just a matter of weeks.

Imagine if by the end of April or the beginning of May this nightmare was drawing to a close.

Imagine if we could see light burning brightly at the end of this very dark tunnel.

Imagine the hope we would have, the confidence it would instill, the stability it would restore to our markets and to our society.

As we emerge blinking into that light, chastened and changed, it will be into a new reality, one attended by weekly testing for CoVID-19 to ensure that it will not terrorize us again.

I have no doubt that we can do this.

But we must demand that our leaders take action today.

We must revive the spirit of Winston Churchill for the fight that lies ahead:

We must fight on the beaches. We must fight on the landing grounds. We must fight in the fields and in the streets. We must fight in the hills. We must never surrender.

Never, never, never.

Originally published at on March 21, 2020.

Pediatric Emergency Physician

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