Two parts of the equation: "Flattening the curve" and "raising the line".

We read with interest the editorial by Tandon (2020) and the article written by Jenson (2020). We appreciate several of the points raised in the article by Jenson (2020) and would like to discuss a few of them in particular in our correspondence.

First, we would like to point out that “flattening the curve” is not the only defining graphic of the Coronavirus Disease 2019 (COVID-19) pandemic but we also need to “raise the line” of our healthcare capacity. It is clear that health systems and health workers worldwide are under tremendous stress from the growing pandemic; reports of overworked healthcare staff (Ng et al., 2020) and delayed access to care (Lazzerini et al., 2020) are not uncommon. Importantly, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is dissimilar from the common flu or other coronaviruses: it is much more contagious and infected persons may remain relatively asymptomatic (Yeo et al., 2020; Wang et al., 2020). Hence, previously published United States Centers for Disease Control and Prevention guidelines may not be directly applicable in this instance.

The COVID-19 pandemic represents a serious burden on healthcare systems as cases increase at an exponential rate and may have complicated needs. In many countries, intensive care units (ICUs) and mechanical ventilators, which are needed for treating severe COVID-19 cases, are also in short supply (Tanne et al., 2020). This is also why stringent ‘lockdown’ measures may be necessary to allow time for the health systems and medical staff to recover as cases may continue to require intensive care and take weeks before they are discharged (Kim et al., 2020). Even though the daily number of COVID-19 cases reported may be declining, the crux is that health systems need time to recover and discharge existing cases. In fact, the United States Centers for Disease Control and Prevention (United States Centers for Disease Control and Prevention, 2020) and some countries (including China and Singapore) (Qu et al., 2020) still recommend two consecutive negative respiratory specimens, collected more than 24 h apart before discharge or discontinuation of transmission-based precautions.

In addition to handling COVID-related cases, health systems also need to continue to attend to other emergencies and sick persons requiring hospital admission. As with all things, individuals would continue to fall ill with occasional infections and complications or acute exacerbation of their chronic conditions. This is “raising the line” of our healthcare capacity, which would only succeed if we also “flatten” the curve of COVID-19 cases as resources are ultimately finite. It is a mammoth-logistical task for hospitals to redistribute and recruit manpower and increase the number of available beds and staffing. Most hospitals have resorted to cancelling non-urgent outpatient reviews and elective procedures, as well as telemedicine services whenever possible (Tanne et al., 2020). It is important to ensure that the provision of medical care is not significantly compromised and the supply of critical medications and personal protective equipment (PPE) remain adequate throughout the pandemic. Hence, we need to keep the curve of COVID-19 cases below the capacity threshold; this is a difficult balance and a certain degree of caution albeit excessive may be necessary to ensure that demand does not outstrip the available resources.

Second, in the article, Jenson (2020) argued that, “In addition to the societal and financial impact, citizens of the US have had significant curtailment of individual and constitutional rights—such as the right to assemble—and state-imposed restrictions on personal activities and travel. These actions have quarantined not just patients with COVID-19, which may be justified on a public health basis, but also in effect quarantined the healthy.” Newer studies have pointed to a previously underappreciated reservoir of asymptomatic spreaders (Day, 2020; Ye et al., 2020). In a recent report by China’s National Health Commission, a significant proportion of the COVID-19 cases had mild to no symptoms (World Health Organisation, 2020). This could affect our earlier interpretations and has important implications on transmission dynamics, mass testing and quarantine policies. This also means that without testing, we would not be able to tell if an individual has been infected by the SARS-CoV-2. Without mass testing, the only other alternative is mass spatial distancing and isolation to stem possible viral transmission.

While we agree that “there is not consistent evidence that countries or states that have been strictly locked down are uniformly faring better than states that have not” (Jenson, 2020), we would argue that a low number of confirmed cases may not reflect better outcomes but a lack of testing on the ground, as in the case of many African countries (The Economist, 2020). Although the utility and costs of a complete lockdown may be questionable (Jenson, 2020), there appears to be value in implementing strict social distancing measures early, as exemplified through successful case studies of countries like New Zealand, Germany, Hong Kong and Taiwan (Cousins, 2020; De Deyn et al., 2020).

In sum, we agree with Jenson (2020) that fear is contagious and ‘lockdowns’ are not a ‘one size fits all’ solution, it has to be customized for each milieu, state or country. Appointed government leaders and officials should be attuned to the needs on the ground. A government that asks its people to trust it more, must first exude leadership, be transparent and earn that trust. Apart from the chaos and swelling crowds of desperate migrants trying to get home, we witnessed many supply chain issues and food shortages when India enacted a nationwide lockdown for its 1.3 billion population (Goyal et al., 2020). Lockdown is not a magic solution but it does slow the transmission of COVID-19. There is no universal definition for what constitutes a lockdown. We would echo the words of Dr Maria Van Kerkhove, technical lead at the World Health Organisation (WHO), that lockdowns are “a set of measures countries have taken that include individual- and community-level restrictions of movement. They can include full- or partial closures of different types of facilities, such as schools or workplaces.” (Lacina, 2020)

Ethical approval

Not applicable.

Financial disclosure

None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None.