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Bioethics Forum Essay

Flattening the Curve, Then What?

The metaphor “flattening the curve” has succinctly captured the challenge of responding to the coronavirus pandemic in the United States. With no vaccine or effective treatment, the use of social distancing measures attempts to delay the spread of infection and keep the need for intensive, hospital-based health services within the capacity of our health care system. Unfortunately, too narrow a focus on flattening the curve may obscure larger gaps and deficiencies in our public health system that we have long ignored and must address.

Besides lowering the peak demand for health services, the “flattening” approach includes raising the baseline of available resources, such as coronavirus tests, hospital and ICU beds, ventilators, personal protective equipment, and trained health care workers. In short, we need greater surge capacity. Although a lack of funding for public health infrastructure and personnel is evident, another key reason for a lack of surge capacity is that excess capacity is inconsistent with the business models of for-profit hospitals, bottom-line sensitive nonprofit hospitals, and underfunded public hospitals. Most hospital administrators and executives traditionally have sought to increase utilization rates and eliminate excess capacity, such as empty beds and unused equipment and supplies.

The nationwide pandemic also highlights the fragmentation of our public health system. Unlike most countries, the U.S. has no national public health agency, with public health primarily the responsibility of state and local governments. Many jurisdictions lack the financial means or expertise to respond to a public health emergency, including the ability to manage quarantine or other mandatory social distancing measures. The authority of the Centers for Disease Control and Prevention is limited to controlling international and interstate health threats, as well as  providing research, education, laboratory services, data collection and analysis, consultation, and policy recommendations for the states. A more centralized public health structure, regardless of the merits, would run counter to practices in place since colonial times and reflected in the Constitution’s separation of powers between the federal and state governments.

Flattening the curve means delaying the spread of infection and expanding the time needed to impose social distancing measures. The economic and social consequences are distressing to contemplate, as schools, businesses, houses of worship, and entire sectors of society will be unable to operate normally. Sports, entertainment, civic, and cultural events with even modest attendance will be unsafe so long as the virus is present and transmissible in communities.

Thus, flattening the curve is not a long-term strategy; it is a short-term necessity thrust on the nation by our failure to plan for an inevitable public health crisis and our tragically inadequate response in the early days of the coronavirus outbreak. Our slow initial reaction, especially the inability to initiate meaningful levels of testing, limited our options and committed us to our current strategy. By comparison, Taiwan overreacted to the SARS epidemic in 2003, and placed 132,000 people in home quarantine, which identified only 2 cases and caused widespread panic. Determined not to repeat the same mistake, the government rejected indiscriminate quarantine. Instead, it aggressively screened travelers, and promptly instituted widespread testing, contact tracing, and isolation. As a result, despite being 81 miles from mainland China, Taiwan only had 195 cases and 2 deaths from COVID-19 as of March 23, 2020.

 As we contemplate future systemic changes, we must not lose sight of the insidious role that partisan politics continues to play in our public health policy. In early 2009, the U.S  faced an emerging threat from H1N1 flu. Some 80 to 90 million Americans received the vaccine, but 70 million doses went unused and had to be destroyed. The country was relatively fortunate because 60 million people were infected, with 274,000 hospitalizations, but “only” 12,469 fatalities (compared to 400,000 deaths worldwide). According to one study, the willingness to get the vaccine was highly correlated with an individual’s political party affiliation. Today, we have even worse political divisions, and influential cable news pundits who denied any threat contributed to the slow response to the coronavirus outbreak.

Public health measures can only succeed if there is a high degree of social solidarity, which requires trust in public health agencies and their leaders. It is imperative that the U.S. develops a nonpartisan leadership model for our public health institutions. Public health officials should have the gravitas, broad political support, and courage to confront public figures who dispense ignorant, divisive, and conspiratorial justifications for disregarding essential public health recommendations. If we fail to undertake a comprehensive revamping of the nation’s public health structure, our society, and not just the curve of infection, will be flattened. 

Mark A. Rothstein is the Herbert F. Boehl Chair of Law and Medicine and Director of the Institute for Bioethics, Health Policy and Law at the University of Louisville School of Medicine. He is a Hastings Center fellow.    

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  1. I believe the concept of flattening the curve is going to end up being a major concept that will impact a lot of areas and relate to networks and people connected. I see cities will not be the same. People will spread out, and the Internet will become much larger. Society will need to make the changes. This is an acceleration of past trends, and as business adjusts, working from home is going to get baked in. This is huge. I am calling this era we are now in, “The Great Flattening”.

  2. Flattening the curve is a concept to keep us from being overrun , but never a strategy to prevent death from the disease itself, only from the lack health care resources, PPE, ventilators, disinfectants and to get knowledge of the nature of the disease.

    Controlled spread, limited high risk exposure, limited viral inoculum and interventions to allow immunity to build without putting the health system in an overburdened state is truly what we are hoping for.

    The false pretense that were a few months from a workable vaccine or treatment is consistent with what our past experience has shown.

    Finding a prudent middle ground of opening up our countries and living thoughtfully in a manner that decreases undo death is likely the best we can hope for. Pretending that because we shut the world down were saving lives…, well, weve got no evidence that’s the case if our health services aren’t overcapacity.

    Social distancing and limiting over exposure while opening up our economies in a controlled atmosphere of watchful waiting as assessing is likely the best we can hope for.

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