Why Flatten the curve

We all feel a sense of urgency to get control over this darned COVID-19. It has been encouraging to see just how seriously most of us have taken the advice of our Public Health authorities. Even those who thought this was making a mountain out of a mole hill at first are starting to realize that it is serious. It’s scary to watch what is happening in Europe.

Our schools, restaurants, theatres have been closed. We are staying home in droves and our numbers in Canada are still going up. I’ve been asked why that is so if we are trying so hard to comply with the Social Distancing advice. We are sacrificing and not (yet) seeing a benefit. What gives?

There are a few things we have to keep in mind. This virus has been in our community, hovering unseen for a few days or maybe even weeks. It has an incubation period of around 5-7 days and maybe even up to 14 days. It can remain viable and infectious on shared hard surfaces for a few days. This means that even before we started the Social Distancing in earnest, there were some of us who had been exposed, maybe thought it was a cold, and unwittingly spread it to others. So even if we all locked ourselves up 100% it would take a couple of weeks to know whether that strategy was working because some of us would come down with symptoms from being exposed prior to our isolation. We have to be patient and persistent in order to see the results of this effort.

Secondly, we have had an influx of patients who have come home from other countries. Initially this was Canda’s main source of new infections. Unfortunately, before they were aware they were sick, they were able to pass it on. So we are getting a bit of a surge from that source and their contacts. Hopefully this will not blossom again when we have an influx of people coming home from winter vacations, March break or international travel. IT IS IMPERATIVE THAT PEOPLE WHO ARE RETURNING TO CANADA FROM ANY OTHER COUNTRY SELF ISOLATE FOR 2 WEEKS. THIS MEANS STAYING AT HOME. DO NOT EVEN GO TO THE GROCERY STORE. HAVE SOMEONE DO GROCERY OR PHARMACY RUNS FOR YOU AND LEAVE YOUR ITEMS AT YOUR DOOR. Without this cooperation from our returning friends and relatives, we will expect another surge and wider spread.

Another thing we have to keep in mind is that we are trying to flatten the curve but we can’t elminate it. There will be infections. But can we keep a handle on them enough to adequately maintain our health care system so we can look after ALL our people, not just the COVID-19 patients.

The graph below shows how rigid restrictions have been effective in South Korea, Hong Kong and even China. Reported new cases in China in the last 24 hours have been less than in Canada (13 in China as opposed to over 50 in Canada.) Their restrictions have been dramatic and very rigidly enforced for a month or so. But they are winning. We want, a month from now to be winning as well.

Canada’s numbers are still on the rise. Can we change the angle?

I have been watching the numbers on Worldometer that are updated daily. If you are anxious about COVID, maybe you would prefer not to look at these. They show daily numbers – total cases, number of new cases in the past 24 hours, number of new deaths, total number of deaths and number of people who have been diagnosed and recovered. The last column, the number of cases per million population, is the one that interests me most and will be the one that we want to see level off if our management is being effective. Currently Canada has 17 cases per million population. Compare that to Italy where that figure is a startling 591. Our cases per million number will rise quite a bit over the next two weeks but if we are successful it should start to become more stable. That’s what flattening the curve means.

Realistically, we should prepare ourselves that the restrictions are not just going to be a 2 week thing. We are in this for the long haul. It is going to take several weeks or even a few months to get this to a manageable level. I can’t imagine that schools will reopen before the end of this school year. We will have to adopt these principles of Social Distancing for the next foreseeable future. Eventually we will find a medical treatment for this, I think. Immunization will be developed eventually as well. With time, there will have been enough people who have had the virus and recovered with some natural immunity to lower the prevalence and thereby lower the potential of spread. We need a concerted effort from everyone to tackle this. It will sort out. But it will take time. Hang in. Stay the course.

For a bit more on Flattening the Curve and Social Distancing, check out my last blog article here.

John A Geddes MSc MD CCFP

Kingston, Canada

March 18, 2020

I have had some excellent questions come to me as a result of my recent blog articles and am happy to respond with my opinions which are, I hope, knowledgable but I will reiterate that I don’t claim to be a world expert. I am giving you my opinions as a local family doctor and neighbour.

One question that I thought was a very good one went something like this. “If the number of cases under the curve on the graph are the same, the blue ones the same as the red ones, why don’t we just let this virus run it’s course and get it over with quickly since the curve shows that the illness will deplete faster with the red curve. Get it over with.”

If we quickly look at the graph, that seems like a very logical question and the idea that eventually at least half of us are going to get this virus, one way or another, would suggest that we might as well just bear it now and get on with it. More people will have immunity and the virus will run out of steam.

The problem with this view is that we are not looking at that dotted line that indicates what our Healthcare System capacity is. If we go for the red curve you can see that very quickly we will overwhelm what resources we have to manage it. Conceivably the number of people infected if it is totally out of control might not be 50% but 70%. As a consequence, many more people will die because they will not have access to life-saving ventilation or hospital care.

A younger demographic may argue that the severe illness and death rates are in the elderly and those with chronic illnesses mainly. That fact is true, but others do succumb from this virus. And if the hospitals and medical staff are depleted of resources and spaces, where will your kid go when they are hit by a car and have a head injury, or you have a heart attack and need bypass surgery, or your sister needs cancer surgery or your wife has a postpartum bleed? The argument is not entirely about suppressing the total number of cases, but about making the inevitable manageable so we can continue to provide adequate health care to all.

I think many senior folks (I don’t like being called elderly) will agree with me that we might have a bit of a fatalistic attitude to the prospect of death from this virus. We realize that we will all die sooner or later. For those of us over 70, there is a bit more sooner and a bit less later in that equation and we know it. Sure, we think about our increased risk, but I suspect most of us worry more about our families and friends than ourselves.

To put this in perspective, let’s say in the greater Kingston area we have about 200,000 people. If half of those gets COVID-19 in the next few weeks that means 100,000 infections. Of those, 80,000 will take acetaminophen, stay home from work, feel lousy but get better. That will mean 80,000 people off work for at least two weeks, by the way. Another 10,000 will need some sort of medical care and a further 10,000 would benefit from hospitalization. Do we have 10,000 hospital beds to offer them? Even more drastic is that 5,000 will need ventilation. We have 35 ICU beds currently at Kingston General Hospital and they are usually full with people who need immediate intensive care with things other than COVID-19. So where will these 5000 people get their needed intensive care? Maybe we could handle it if they came in slowly but in a glut, the system would be overwhelmed and unmanageable. Bear in mind that with a high peak that means more health care workers would also be ill and out of commission to serve as well.

The proposal is that if we follow the advice we are receiving for Social Distancing (in addition to all the handwashing, sleeve-sneezing advice) we can spread these infections out over time. Flatten the curve. Perhaps, if we can slow the spread over the next few weeks or months, science will come up with an anti-viral medication that can blunt the curve even more. Eventually there will be immunization available. People will develop natural immunity. With time the infection rate will slow down. China has put very stringent social interaction controls in place. In the last 24 hours, China has reported 24 new cases. Canada has had 89.

I present this to you to emphasize that we need to be doing everything we can NOW to minimize the shape of this curve and keep the inevitable crisis to within manageable bounds. I saw a headline somewhere that said “This is not a snow day.” We will all be required to sacrifice in some way in order to keep our community as safe as possible from a situation that could overwhelm our Healthcare System and be detrimental to us all, not just our vulnerable elderly neighbours and relatives. We can not just think about “me” but rather aim to help “us”.

Update March 18, 2020 here.

John A Geddes MSc MD CCFP

Kingston, Canada

March 15, 2020.