The Flattening Lie

Time has been radically compressed in recent weeks in New York, so perhaps we can all be forgiven a little disorientation. Was it just a week ago that we were all talking about flattening the curve? It seems that that furor has died down as the crisis proper takes hold of us, and perhaps that’s because it was an ideology whose relevance for us was short-lived. We all believed it for a time – when we were desperate for a hope beyond hope that what was happening wasn’t happening; that it might actually be possible, after all, to confront the pandemic and still continue to conduct normal life, business as usual, with only minor modifications – but now that we’re here, maybe we’ve started to recognize the flattening craze for what it was: A lie. Or simply to forget about it. Or perhaps these words still seem like sacrilege to you?

Some brief background here before you start to think that I’ve lapsed into pandemic denialism. We all know that the President and his Administration betrayed us and committed a crime of historic proportions. We have all – New Yorkers, at least – seen with our own eyes the failures of our Governor and our Mayor (though I, for one, will admit that now that the Mayor, forced out, has exited stage left and the Governor has taken center stage, he’s proving – in this crisis which it was in large part his responsibility to avert – as forceful and energetic as he always proves when it comes time to break out the baseball cap; for this keen observation regarding the emergency headwear of choice for New York politicians, I’m indebted to my ever-perspicacious partner).

Still, there was a time – perhaps only a few days ago, a week at most – where it seemed we all became convinced that if we just flattened the curve enough, everything would be okay, or almost.

flattening_the_curve_final.jpg
It was under the influence of this image that we were all deceived. I got this image from Vox, which, as you can see, got it from the CDC.

But what if the flattened curve-versus-healthcare system capacity image looked like the following instead?

Screen Shot 2020-03-22 at 3.23.36 PM.png
This image is drawn from the now-widely-cited report of the Imperial College COVID-19 Response Team entitled “Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand”; note that the red line at the graph’s bottom represents the “[s]urge critical care bed capacity” which is to say, the healthcare system capacity in this instance. If the report’s conclusions are at all accurate, it suggests that the flattening-the-curve enthusiasm in New York was nothing more than a cruel joke.
The image above suggests that no amount of flattening – using the various measures with which we’ve all become intimately familiar in recent weeks (as you can see, they consider case isolation, household quarantine, school closures, and social distancing, among other interventions) – could or would have proved sufficient in our current crisis. Even the flattest of the curves exceeds the healthcare system capacity by orders of magnitude.

The plot continues to thicken, though, as the Imperial College London (ICL) report in turn came in for some harsh criticism from a team at the New England Complex Systems Institute (that included Nassim Nicholas Taleb) in a review which includes some dense statistical jargon, but can basically be boiled down to a claim that the ICL team made false assumptions about how the virus spread (ignoring “super-spreader” events and therefore drastically undervaluing the importance of banning large gatherings) and totally ignored the most effective strategy – a combined approach, a la South Korea, of extensive testing, aggressive contact tracing, case isolation, and home quarantine for the potentially exposed. The jargon gets a little much here, but basically, all the flattening-the-curve approaches can be grouped under the heading “Mitigation,” while the approaches taken by South Korea, China, and to a lesser extent, more recently, Italy and Spain, can be grouped under the heading “Suppression.” Mitigation doesn’t seek to limit the total number of cases (it only spreads them out to “buy us time”), while, in theory, suppression does, by radically curtailing the spread of the virus and then employing surveillance measures to prevent its resurgence.

The ICL team – wrongly according to Taleb and his NECSI co-authors – concluded that a suppression strategy would simply delay an inevitable peak in cases once drastic measures (eg, lockdown, shelter-in-place, stay-at-home, etc.) were relaxed, and included the following graph in their report:

Screen Shot 2020-03-22 at 3.31.57 PM.png
Basically, according to the ICL report, either we pay the price now, or we pay the price later. Regular readers may note a similarity to the title of a piece of mine from last week, but the meaning of my title was actual the reverse of the report’s implication. Obviously, the above does not leave policymakers any appealing options – either destroy the economy in the short-term, but still suffer pandemic later, or just suffer pandemic now with all its horrifying consequences.

Enter the Internet’s most coronaviral pandemic influencer, Tomas Pueyo (this is tongue-in-cheek, of course, as I, too, am not an epidemiologist or healthcare professional). Building on the NECSI review, Pueyo and his fellow researchers (“a group of normal citizens working around the clock to find all the relevant research available to structure it into one piece, in case it can help others process all the information that is out there about the coronavirus”) advocate for a strategy that they’ve given a corny name – which can be inferred from the image below:

1*ok3NLISRGvK-4SQyDA5KTg.png
The Medium post from which this image was drawn has been viewed ~5 million times so far.

Long story short, they argue that contrary to the assertion of the ICL report, and following the example set by South Korea – among other East Asian countries / semi-autonomous zones that learned from the experiences of SARS and/or MERS – it is possible to first suppress the virus, then contain it through ongoing measures (again, testing, contact tracing, case isolation, home quarantining, etc.) while significantly relaxing lockdown / shelter-in-place / stay-at-home orders. This, of course, should be music to all our ears, to the extent it proves correct, but it flies in the face of the flattening-the-curve common sense to which, it seems, almost all of us came to subscribe almost overnight.

This quandary, I guess, reflects both the power and pitfalls of Internet culture, and points to the difficulty of confronting a pandemic when public health budgets have been radically slashed; governments themselves seem to be turning to non-specialist online influencers to shape their own policies. Sometimes, this may result in enlightened approaches, but it is a touch worrying, to say the least. My partner shared this curriculum from “a group of students at Harvard Medical School” who “created a Response Team to organize their efforts against the COVID-19 pandemic. As a key resource, the curriculum references none other than Pueyo’s pieces, and I don’t think I’m flattering myself in suggesting I could’ve written it.

Not saying it’s the blindfolded leading the blindfolded, but clearly, there’s an urgent need for coherent, evidence-based strategies, and we should all be holding ourselves to high standards about what we do and don’t know (and how) as we strive to rapidly make sense of what we do next to avert an even worse catastrophe than that to which we’ve already committed ourselves.

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