Rather than ‘flatten the curve’ it is time to ‘crush the curve’

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This story was sponsored by the Northeast Ohio Solutions Journalism Collaborative, which is composed of 20-plus Northeast Ohio news outlets including Profile News Ohio and several other Neighborhood & Community Media Association of Greater Cleveland member outlets.

by Rich Weiss and Julia Bejjani

The colder weather has brought with it the predicted spike in new coronavirus cases to the State of Ohio—and the rest of the world—as we all gather more closely, indoors.

In recent weeks, news about vaccine trial progress has brought hope to a coronavirus pandemic-weary global population—particularly those coping with the loss of family, friends, and colleagues to the lethal virus.

The fatigue of this pandemic, mixed with a seemingly insurmountable surge in new cases this fall, plus the hope of vaccines on the horizon, all together could lull us into relaxing our fight to contain coronavirus just as we reach our most dangerous levels of community spread.

Jade Khalife, MD, MPH, MSc., health systems practitioner and researcher for Lebanon’s Joint Health Systems Research project, is arguing that the time is now for Lebanon—and the world—to replicate a set of coronavirus containment policies, called, “crushing the curve,” which show better results than the more widely adopted “flattening the curve” policies.

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Khalife explained the rationale behind our current, more widely-adopted virus containment method: “The main idea is that flattening means you generally accept it will harm the same amount of people as without doing anything (i.e., letting it loose), but you spread it over a wider timeline.  The purpose of that is to allow your healthcare system to cope and not get overwhelmed.”

Khalife put this in disease-control terms: “To flatten the curve, you need to suppress the virus transmission to an extent that on average one case infects one other case (i.e., reproductive number ‘R’ is = 1). Without doing anything, the R of COVID-19 is about 3-5, depending on the country.”

By contrast, the ‘crushing the curve’ solution first requires suppression efforts to drive the disease to levels at or near zero; once achieved, mitigation systems switch gears to a nationally coordinated virus containment system.  The idea is to return to containment (few cases) and push towards elimination (zero cases).

“Crushing the curve means you want the curve to steeply decline, to a low/very-low level, usually one that allow you to go back to ‘containment’, your contact-tracing can cope, and of course your healthcare easily can as well.  But the goal is to protect as many people as possible, and not accepting that large numbers will be harmed (even if in a longer timeline),” said Khalife.

Again, in disease-control terms: “To be able to make such a steep decline (i.e., crush), the R needs to be lower than 1, the lower the better. In Wuhan, China, they crushed it [down to an infection rate of] R=0.3.  Several other countries did it as well, thereafter. The lower the R, the less time you actually need to have the intervention (e.g., lockdown).”

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Aside from Wuhan, Khalife credits the “crushing the curve” virus-containment method with successful infection rate reductions in the less-affluent nations of Cambodia, Cyprus, Latvia, Slovakia, Slovenia, Thailand, Tunisia and Vietnam, but also points to successes in Australia, Iceland and New Zealand.  Similar ‘suppress and lift’ approaches have been formally advanced elsewhere in the world, most notably in Hong Kong and Singapore.

In September, Khalife and other concerned Lebanese medical community members believed the challenge required a new organization to recommend national policy.  They formed the Independent Lebanese Committee for the Elimination of COVID-19 (zerocovidlb.wordpress.com).  “I realized in April that there was insufficient progress towards making a national strategy; Lebanon still lacks one,” Khalife explained.  “I took to social media to exchange thoughts and connect with like-minded persons. In September I publicly asked who would be interested in having a more in-depth discussion at the strategic level, regarding COVID-19 in Lebanon.”

During Khalife’s discussion and follow-up email exchanges with Profile News Ohio, the Lebanese government decided on a 2-week lockdown to begin on November 14, but, according to Khalife, “They do not have a strategy beyond this period.”

Khalife and his organization, however, do have a strategy beyond this period: “We have made a strategy which we released last week and are advocating the government to adopt it.”

He summarized, “In Lebanon, since case levels are too high now and COVID is widespread, our group would like to see the curve crushed, at least down to a level where we can return to containment, within our national capacity to test, contact-trace, and hopefully also quarantine and isolate.”

When asked about limitations of the “crushing the curve” solution, he pointed out, “It is harder for some places to crush the curve than others, but I think they certainly should work towards it, and not just accept ‘flattening’, because it does not protect most people, and most places have the capacity to do more than that but require political commitment and a formal strategy.”

Here at home, it stands to reason that Ohio’s Arabic and Middle Eastern communities would see the same benefits other communities have seen from the implementation of “crushing the curve” policies, locally.  Like in Lebanon, it stands to reason these policies would be most effective with the clear national strategy Khalife and his colleagues call for nationally, in Lebanon.  But, Khalife noted in a follow-up email, even before seeing progress toward a national strategy, “Local communities can act and limit COVID transmission, because most cases are hyper-local, happening very close to where people live.”

In this, the most perilous phase of the coronavirus pandemic yet, it is incumbent on populations and governments to engage in sober thinking to plan the safest and most strategic endgame for COVID-19 possible, particularly as we begin to hear news about potentially positive vaccine trial results.

To avoid exceeding healthcare capacity and sacrifice the fewest lives possible, we—and the rest of the world—would do well to study clear and proven strategies like “crushing the curve” and moving towards COVID-19 elimination.

Now, more than ever, following proven, successful solutions will be vital for populations across the globe to better withstand the virus through the coming perilous months as we await a widely distributed, effective coronavirus vaccine.

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