It is no exaggeration to say ‘flattening the curve’ has had a profound impact on how governments and the general public view public health and the provision of healthcare.
Instead of traditional concepts such as minimizing ill health in society, during the SARS-CoV-2 pandemic, attitudes have been changed to accept that healthcare exists in order to provide a workforce with sufficient capacity to keep the economy functioning. Instead of optimizing the pandemic response for the best health outcomes, which also helps the economy long-term, the default position adopted by most governments established a new principle that the total amount of human suffering caused by disease is not important, only the immediate stress on healthcare systems. This principle continues to be dominant to this day, even in the face of the suffering caused by Long Covid and the high excess deaths seen globally, many of which are a consequence of acute infection or the complications or sequelae of infection by SARS-CoV-2.
SARS-CoV-2 emerged in late 2019 in Wuhan and began silently spreading beyond China. But it took some time for caseloads to build up and for the tsunami of severe pneumonia to hit hospitals around the world. This happened in February 2020 in the first hard hit countries (e.g., Iran and Italy), and in March-April in most others.
In that critical period, when experience of the SARS-CoV-1 outbreak told us containment should have been the sensible response, the public was subjected to a barrage of minimizing and obfuscating messages, and containment wasn’t even attempted.
In the first days of February 2020, we regularly saw quotes such as “the risk to Americans is relatively low and there is no justification for extraordinary, draconian action”2, “If panic was commensurate with the virus’s prevalence or symptoms, one might expect to see more paranoia around the flu than the coronavirus.”3, “Ordinary seasonal flu leads to about half a million deaths every year globally. Yet we barely take notice of flu but feel imperilled by new diseases”4, as well as statements from nominal experts openly expressing the attitude that containment should not even be tried (“resources are better used [...] treating sick patients and developing vaccines and other countermeasures”5).
Eventually, however, governments panicked when faced with the imminent collapse of healthcare systems and the prospect of millions being triaged and left to die at home, and finally acted to implement non-pharmaceutical interventions such as general quarantines (that came to be known as “lockdowns”), border controls and mask mandates.
At this point we transitioned from the era of minimizing the threat to the second stage of the pandemic, when many governments switched towards the pretense of doing infection control. This is when the “Flatten the curve” catchphrase entered the political dialogue. What did it mean? The pernicious idea behind it was that “slowing the spread of the infection is nearly as important as stopping it.”1
What does it mean to “flatten the curve”?
The ideal goal in fighting an epidemic or pandemic is to completely halt the spread. But merely slowing it – mitigation — is critical. This reduces the number of cases that are active at any given time, which in turn gives doctors, hospitals, police, schools and vaccine-manufacturers time to prepare and respond, without becoming overwhelmed. Most hospitals can function with 10 percent reduction in staff, but not with half their people out at once.
Some commentators have argued for getting the outbreak over with quickly. That is a recipe for panic, unnecessary suffering and death. Slowing and spreading out the tidal wave of cases will save lives. Flattening the curve keeps society going.The New York Times1
The disturbing reality behind this strategy should be obvious – there was never any intention to stop the spread of the virus, and stated policy from the outset was to hope for herd immunity or failing that, make it endemic - always circulating at a constant level. Herd immunity was always an unrealistic prospect given the established body of evidence about the propensity of coronaviruses to reinfect hosts, so endemicity was the only realistic objective. The number of people who got infected was unimportant as long as healthcare systems did not succumb to a state of complete collapse.
While the ostensible goal was to reduce overall casualties, it was not to prevent a huge number of deaths and serious long-term disability, only to stretch it out in time to make it more acceptable to society.
“Flattening the curve” would only have made sense in traditional public health terms if the following conditions were met:
- In-hospital mortality was close to zero, therefore nearly all deaths could be prevented if nobody was left untreated.
- There were no long-term health consequences of surviving the infection, or, at the very least, there were no such consequences if given proper treatment.
- There were no reinfections and, once society got past the initial wave of infection, the virus would indeed largely go away (as promised by many proponents of uncontrolled infection).
- If it was certain that eventually highly efficient vaccines would be developed that would solve the problem for good, meaning that slowing down infections in the short term rather than stopping them altogether early on with quarantine measures and non-pharmaceutical interventions (NPIs) was sufficient in terms of buying time to develop a real, much less disruptive solution.
- It was certain that eventually highly effective treatments would be developed that would make the disease a non-issue.
All of these assumptions were either already false the moment they were made, or they were completely unwarranted.
- Especially early on, in-hospital mortality was in fact very high, and most of the many thousands dying every day in Europe and the United States died in a hospital bed. There was not much that could be done once severe pneumonia developed.
- Before SARS-CoV-2, we had dealt with SARS-CoV-16-10 (which, fortunately, was contained). Our experience of SARS-CoV-1 told us survivors of SARS infection often have to deal with very serious long-term or permanent health issues11-17. The moment the first SARS-CoV-2 sequence was made available, it was obvious that what later became known as Long Covid was going to be a massive problem.
- Similarly, it had been known for decades that immunity against coronaviruses is fleeting18-20. Therefore, basing public health policy on assumptions about lasting immunity after SARS-CoV-2 infection was the height of irresponsibility, and in fact outright malpractice. Indeed, subsequent events rapidly proved that assumption wrong, and we now know humans are expected to experience many SARS-CoV-2 infections in their lifetimes.
- While previously endemic coronaviruses in humans had not been a major public health issue, they are in domestic animals, and a lot of experience had accumulated designing vaccines in that context21. That body of knowledge told us in no uncertain terms that we should not expect to be able to vaccinate our way out of this problem – coronavirus vaccines in the past had worked at best moderately well, but even when they did work, they did not last very long due to the combination of very fast antigenic evolution and rapidly waning antibody titers. Indeed, real life followed the same pattern – viral evolution rapidly destroyed the effectiveness of COVID-19 vaccines while the efforts to catch up with it have always been at least half a year behind it.
- There was also no guarantee that effective treatments would ever be developed. Indeed, now more than three years later, in-hospital mortality has been reduced through a combination of steroids, anticoagulants, monoclonal antibodies, anti-viral drugs, and other medications, but large numbers of people continue to die of COVID all around the world every day, i.e. the disease is very far from being a solved medical problem.
Thus “flattening the curve” meant postponing death and disability, and reducing it somewhat, but not really preventing it. Because immunity is not lasting, it also meant that the curve would never go to zero.
But it is the area under the curve that matters in terms of its overall impact on the population, not its peak. What happened in the end? Early in the pandemic, the IFR (Infection Fatality Rate) in populations with unfavorable demographics were in the 1-1.5% range, reaching as high as 1.63% in the extreme22, while it was lower in countries with younger demographics.
Three years later, we have multiple countries where excess mortality (deaths in excess of that expected from pre-pandemic death rates, with peaks entirely coinciding with COVID waves) has reached or even vastly exceeded what would have been predicted if everyone got infected23,24. Notable examples include several countries in Eastern Europe – Bulgaria, North Macedonia, Serbia, Russia, and others – that are above or closely to excess mortality of 1% of the total population, as well as countries with younger demographics like Peru and South Africa, where ∼0.3% of the population was expected to die at infection saturation but 0.5-0.6% died in practice, because of reinfections and the appearance of deadlier versions of the virus.
Other countries, such as the USA, and most large Western European countries did reduce overall mortality, but only by a factor of 2-3× – they still lost millions of lives and 0.3-0.4% of their population.
A few countries kept infections low until vaccines became available, vaccinated nearly everyone, and only then let the virus loose, which by then was mostly characterized by lower mortality Omicron lineage. Those countries have kept excess mortality in the 0.1-0.2% range, but it has to be remembered that this is only the beginning – SARS-CoV-2 is now endemic, and it will endlessly keep infecting, reinfecting and killing people.
Thus what “flattening the curve” achieved was either to only postpone deaths or to reduce them by some factor but still to what would have previously been considered unacceptable levels, while playing the role of a Trojan horse that made COVID endemic, with all that entails long-term for human health. By meekly conceding to follow such a policy approach, instead of insisting on a real solution to the problem, which would have involved proper containment the way SARS-1 was contained back in 2003, society agreed on previously unimaginable levels of death and disability, in perpetuity.
Managing up to capacity, i.e. human lives do not matter
The “flatten the curve” slogan disappeared from public discourse, but it remained the principle governing pandemic response. The pandemic has been “managed” up to healthcare capacity, i.e., if there is still room for additional critically ill with COVID people in the ICUs, then there is no problem from the perspective of governments and public health institutions. This ignores how many people will die and become permanently disabled – that is not a concern.
This is now the explicitly stated guiding principle of pandemic management, as public health bodies in most countries (if they have not already transitioned into a mode of complete suppression of information by not reporting any data at all) have switched to “monitoring” of SARS-CoV-2 spread only based on COVID-19 hospitalization and severe cases.
Few seem to appreciate what a monumental shift in public health philosophy these events represent. The traditional goal of public health has been to promote public health by eliminating the disease burden that plagued humanity for much of its existence.
No longer. It has now been firmly established that human lives and health are not the priority as long as there is “capacity” in the healthcare system and we are not yet at the point where refrigeration trucks are needed because morgues and crematoria can no longer keep up. This shift in philosophy can be expected to have devastating consequences throughout healthcare and public health. Why should COVID-19 be special and why would anyone expect these practices to apply only to it?
We already see such impacts in many hospital systems around the world, where masking rules have been dropped and no precautions are taken to prevent COVID-19 positives from mixing with other patients, which will certainly cost innumerable lives of clinically vulnerable people suffering from non-COVID conditions. The rot will only spread from there, and standards of care will erode across the board. Why wouldn’t they if we have collectively decided that serious nosocomial infections are something we will just sweep under the rug from now on? And, of course, there will be more pandemics, and we have now established how we are not going to properly deal with them.
The hypocrisy of “we need to save the healthcare system”
Another extremely negative consequence is the loss of trust towards the medical profession and public health by the general public. While most casual observers don’t seem to understand the issues outlined above, the hypocrisy of the “let’s save the healthcare system from collapsing” has been widely felt on a visceral level. After all, what does that imply? Again, it implies that human lives do not matter, yet the healthcare system somehow does.
But what is the healthcare system for if not to save human lives, and why should anyone outside of it care about the “system” and not human life and health?
This obvious contradiction also played a role (among many others) in undermining public confidence in public health institutions and sabotaging even whatever meager containment efforts were launched. It will play the same role in future when we find ourselves in similar situations.
Meaningless oaths, declarations and conventions
We also cannot avoid discussing hypocrisy in a second context. Most medical professionals, including those who actively pushed for unmitigated spread of SARS-CoV-2, as well as those who promoted “flatten the curve” as a substitute for containment, have made some form of the Hippocratic oath, which features statements such as “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.” and “I will prevent disease whenever I can, for prevention is preferable to cure.”
What happened to that? How did we suddenly switch to the view that treatment is good enough even when it falls short of actually curing patients? How is that oath compatible with the idea there is nothing to be done to prevent transmission?
We live in the third decade of the 21st century and have advanced technology that is capable of fully solving the problem, even for a silently spreading virus such as SARS-CoV-2, through respirator-style masks, clean air and mass testing, which can be effectively combined with the traditional practices of quarantine and isolation of the infected. We’re not even using technology to try to stem transmission in settings that are either known to play a disproportionate role in spreading the virus, such as schools25, nor are we attempting to do so in settings where disproportionate harm can be caused, such as hospitals27,26 and care homes28.
The World Medical Association’s Declaration of Geneva29 features statements such as “The health and well-being of my patient will be my first consideration”, “I will maintain the utmost respect for human life”, “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient”.
How did we go from these principles to “short-term GDP growth is more important than human life and health”, “there is no need to stop the spread of COVID because only the old and weak die”, and the numerous other examples of callous disregard for human life and well-being that we have witnessed in the last three years?
A good dose of self-reflection is due in the ranks of the medical and public health professions to reverse these dangerous trends, or there is a chance they will worsen in the future.
Healthcare as a product/service
Finally, we cannot escape the need to discuss one obvious source of the disconnect between lofty moral principles and the ugly reality of real life today, and it is the transition over the last few decades of healthcare and medicine from being a higher calling, aimed at improving the well-being of all of humanity, to a purely transactional business, the primary concern of which is profit generation. In much of the world, including, and especially in the countries with most influence over global health policies, healthcare has been reduced to a series of financial transactions and everyone involved in that process works under the mandate to maximize profits. There is obviously zero room in such a system for naive notions such as maximizing the overall health of the population, eliminating endemic diseases, and other such altruistic objectives.
Healthcare is now seen as a product/service that is received in exchange for payment. And that is all that matters. As long as the product/service is available, there is no problem, and this is how we naturally forget about the “prevention is better than treatment” principle – if by its fundamental design all the system can ever provide is treatment, there is no room in it for prevention.
Besides, prevention generates no revenue. Which has an obvious corollary – once such philosophy has been established, as twisted and perverse as it may sound, it is in fact beneficial to make people as sick as possible, because that maximizes revenue (up to a certain point, of course – there is presumably an “optimal” model for how long people need to be kept alive to maximize revenue extraction).
Again, these have been long-term trends, but there has been very little push back against them from within the ranks of the medical profession and the scientific community, so they developed unhindered. And they laid the groundwork for the official abandonment of public health as we knew it for the last more than a century when the COVID-19 pandemic hit.
Unfortunately, we can only expect even worse in the future, unless drastic course correction occurs soon.