- “In the spring of 2020, as Covid-19 was beginning to take its awful toll in the United States, three words offered a glimmer of hope: flatten the curve.”
- “What we need to do is flatten that down.” – Anthony Fauci
- “For countries staring down fast-rising coronavirus case counts, the race is on to ‘flatten the curve.’”
- “In some ways, flattening the curve did not work as intended.”
- Fauci described the risk of Covid to the U.S. as ‘minuscule’ in late February 2020, and [estimated] ‘two weeks to flatten the curve’” – Wall Street Journal (August 5, 2021)
- “Flattening the curve became an abstraction with no real meaning.” – Head of the Yale School of Public Health Epidemiology Department
- “By 2021, the phrase ‘flatten the curve’ had largely fallen out of medical messaging.”
The logic of zero-Covid was always only half-coherent. A beginning without an end.
Zeroing out the virus involves an aggressive upfront program to suppress and control the pandemic through intensive mass testing and contact tracing, vast quarantines, travel bans, closing of businesses and suspension of public gatherings, extending to full-city or nationwide lockdowns, all at an escalating social and economic cost. But zero-Covid leads straight into a corner. SARS-CoV-2 was never going to simply disappear. It continues to circulate widely in the 175 countries not following an “elimination” strategy. In fact, the virus is constantly mutating – more than 20 important variants have emerged in the past 3 years – becoming more infectious and more virulent. The risk to a country following a zero-Covid policy from both internal and external sources has escalated over time.
Time. That is the key to the logic here. Covid may be kept at bay, for a time… but what is the endgame? What do countries do with the time that zero-Covid buys them? How do they prepare for the inevitable but uncertain “Step 2”?
Public health authorities in most of the 20 or so countries that followed virus elimination policies eventually realized they would need an exit plan. But ending zero-Covid means exposing the population to the full force of the pandemic. A study by researchers at Imperial College in London presented a dire scenario, with simulations of outbreaks under several scenarios. (In the chart here, the flat red line is hospital intensive care capacity.)
The “curve” portrays the threat: “A disastrous inundation of hospitals.”
It was not until effective vaccines became available in late 2020 and early 2021 that it became possible to conceive of viable pathway back to normalcy. If the virus could be contained long enough to achieve near
This idea came to be called “flattening the curve.” It was seen as the best answer to the zero-Covid endgame.
The diagram is practically self-explanatory. If the outbreak can be contained, for a while, the cases requiring hospitalization will be spread out (it is assumed) over a longer period, and will not exceed the capacity of the system to handle it. Flattening the curve was widely touted in the early stages of the pandemic, as the smarter way to manage the pandemic, slowing down and spreading out the impact of the disease. It gave authorities more time to vaccinate the population and expand the capacity of the healthcare system.
Actually, “curve-flattening” had been a trope of the public health industry prior to Covid. It predated the emergence of the vaccines, although it remained rather an abstraction – until Covid struck.
- “Flattening the curve was already a well-understood concept in public health circles. But the Covid-19 pandemic presented the first real opportunity to put it to the test.”
The idea caught on, briefly, with politicians and the public. Flattening is a simple (and perhaps simplistic) policy model, easy to communicate visually, free of the elaborate statistical arguments typical of most epidemiological models. It seems even obvious. It is a rationale for government policy-makers to view zero-Covid, with all its costs, as a temporary program designed to buy time for other measures.
And so, the viral containment program…went viral. Someone named Siouxsie Wiles (a New Zealander, perhaps unsurprisingly – see below) coined the hashtag #FlattenTheCurve and pushed the curve-flattening chart out to the world:
- “Our #FlattenTheCurve graphic is now up on Wikipedia with proper attribution & a CC-BY-SA license. Please share far & wide and translate it into any language you can!”
The concept offered a comforting sense of control, and policy efficacy. For a time, “experts” expressed near unanimous support:
- “Flattening the coronavirus disease (COVID-19) curve has been one of the most important public health targets since the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide.”
and flattening began to drift into the loopy mainstream:
- “Barack Obama with his tens of millions of Twitter followers. ‘Flatten the curve’ became a public health meme — there was even Fauci bobblehead that incorporated it.”
Flattening Falls Flat
Unfortunately, it didn’t really work.
Some countries planned carefully for transitioning out of zero-Covid. New Zealand waited until it had “crushed the curve” before cautiously relaxing restrictions. The island nation enjoyed many advantages – low population density, geographical isolation, high vaccination rates, strong public healthcare infrastructure, and a government capable of implementing full-scale, nationwide lockdowns even in response to just a single new case.
Nevertheless, the carefully planned exit from a very strict zero-Covid regime backfired. NZ saw an increase in the death toll by a factor of 63 times over the following 13 months.
Other countries were forcibly thrust into Exit Mode by uncontainable outbreaks of new variants (Omicron), without much chance to prepare for the post-exit surge.
Hong Kong followed a zero-Covid program very similar to mainland China’s ultra-severe version. To no avail – in early 2022, the Omicron variant overwhelmed Hong Kong’s healthcare system and zero-Covid was abandoned.
Oddly enough, the relative scale of the Hong Kong surge was almost exactly the same as the New Zealand surge – deaths increased by also a factor of 63 times over the following 13 months.
Apparently, it doesn’t matter much how much planning takes place. In all cases of zero-Covid exits, across 20 some nations, there was always a surge in infections and deaths (as described in the previous column – linked at the end of this article). It was merely delayed, not reduced.
There is some concern among researchers now that it may be worse than the peak would have been originally without zero-Covid.
- “The flattening of the curve results in a retardation of the curve’s midpoint, which entails an increase in the final number of infections. It is possible that more lives are lost at the end by this process.”
My personal scan of the numbers so far points somewhat the other way. Zero-Covid policies, followed by a controlled exit, may result in lower cumulative death counts, although the infection and mortality rates during the surge sometimes surpass anything experienced in countries that followed “mitigation strategies” rather than zero-Covid. Still, as shown above (and in previous columns), the surge was merely delayed, not eliminated. It may take some while loner before the full data-set is available to assess this question properly.
“Flattening the curve” proved to be illusory. After the Spring of 2020 – the brief highpoint for this meme – the concept withered out of the public discourse. Google Searches for the term went to zero. By 2021, according to Wikipedia, the phrase was no longer part of the “messaging” by public health authorities.
What About China?
The data from China will never be available, it now seems.
Early on, in 2020, the Chinese authorities deleted, destroyed or forged Covid data systematically. Since the abrupt end of zero-Covid on December 8, 2022, they have simply stopped collecting it. The testing programs have been shut down. The figures published since then are clearly false. It may never be possible to chart the course of China’s post-zero-Covid pathway.
The estimates of what China is facing today, and what the population will face going forward, must therefore be derived from comparative studies of other countries following similar policies, or from demographic and epidemiological models.
Demography does not favor China’s case, as will be discussed in the next column. There are many elderly and rural Chinese citizens, many with low vaccination rates (especially among the elderly) and with inadequate access to healthcare (especially in rural areas). The epidemiological picture can reasonably be inferred from the pattern of zero-Covid exits in countries that have followed policies similar to China.
It is stark. If we take the 63x multiple in Covid deaths over the year following the exit, which was the experience for both New Zealand and Hong Kong (planned and unplanned exits), it would imply death tolls of several million people in the next year. Both NZ and HK have superior healthcare infrastructure, and NZ (at least) had much higher vaccination levels when they lifted the their elimination programs in early 2022.
The main problem China has set for itself is the lack of preparation. They flattened their curve (if we take their word for it) with extreme measures, but they did not take advantage of the time they gained to prepare for the exit. The intensive focus on constant mass testing under zero-Covid drained resources away from investments in hospital facilities that will be missed now. Even basic anti-fever medicines like ibuprofen or acetaminophen are reported to be in short supply in major Chinese cities. Hospital facilities are said to have been overwhelmed. The most critical shortcoming, and the most inexplicable, however, was the slowdown in the vaccination program in mid-2022 – leaving at least 100 million vulnerable elderly citizens exposed.
China’s exit from zero-Covid will follow a pattern similar to what all other countries that have gone through. This may be taken as a certainty. The spike in infection and mortality will be comparable, and quite possibly worse. This implies that there will be millions of Covid deaths in China in the coming year(s). How many millions? We will examine some of the answers to that question in future columns.
What is less certain, but – to speak coldly about human tragedy – more important, for the rest of the world, will be the extent of the economic impact. If China’s recovery is slowed, we will all feel it. That assessment is still unclear. That will be the focus of another future column.