Flattening the Curve vs Shifting the Mean


My name is Aaron and I am completing my final undergraduate year in Health and Community Services with the School of Public Health and Social Policy at the University of Victoria.

In the early months of the current pandemic, I wrote articles applying a public health lens to the current world crisis (Drawing Attention to Public Health). There are obvious populations that are more at risk which in my view should form the basis for a measured approach to public health measures.

One established way we conceive of population health is by assessing risk levels and addressing those risks through education, targeting high risk behaviours.

Regulations can have the impact of reducing the overall incident of disease in an entire population, such as speed limits on highways, which reduce the overall incidence of accidents that lead to serious injury or death. Interventions such as mandatory masks during a pandemic make sense in certain kinds of spaces where there is more risk, such as long term care facilities and acute care settings.

Targeting smokers with health information that could encourage them to make a better decision is aimed at those who engage in risky behaviour. We can address smoking behaviour on the population level by regulating the minimum age for purchase.

Risk assessment is important when considering the individual’s choice – to smoke or not to smoke. Another, perhaps more effective, approach is to “shift the mean”, lowering the overall risk to the entire population. Punishments for people who sell cigarettes to young people helps create further deterrents. So, less people overall smoking.

This is good news, because we don’t have to address all the risky behaviour if we can make the whole of society safer.

Flattening the Curve

I have been hearing consistent messaging from our government, media, and other organizations that my personal choices will impact others by increasing or lowering my risk of infection and transmission.

Some things that we do are considered more risky during a pandemic, like going to a party, dancing at a club, or attending a high intensity fitness class.

These risks are more dangerous when these behaviours are combined with close contact with so called vulnerable people – those more likely to contract Covid and tend to have serious medical consequences. So, risky behaviour can look like reckless partying, followed by shift work at the old folks home. Not a good idea.

We are told that our behaviour can help to “stop the spread” or that we need to modify our lives in order to “flatten the curve”. These are individual choices, aimed at addressing risky behaviours, so that people are safer in their lives, and do the right thing to help protect others. Yet even the most diligent practitioner of hygiene is still at risk, and the individual is at a loss how to change the reality of a pandemic for the population as a whole.

Shifting the Mean

So how do we shift the overall morbidity (rate of disease) and mortality (death rate) from Covid? Identifying those who are most at risk is important, and there are also ways that we can lower the overall risk to the entire population.

Sick benefits for all permanent workers.

We know that people who cannot afford to miss work when they are sick will go to work sick instead of missing their shift. Paying people to stay home when they are sick lowers the overall risk for all workers.

Supporting seniors to stay in their homes and continue to maintain independence.

Increased home support for people to remain at home keeps more seniors away from densely populated seniors living facilities, long-term care facilities, or nursing homes.

Having a nurse, care aid, or outreach worker support seniors at home makes sense, and although it may be costly to provide this home support, these people will be less exposed when outbreaks happen.

Photo by Raychan on Unsplash

Increasing the capacity of our ICU and acute care hospitals.

More capacity means that we can serve more people in crisis.

Who does not want more ICU beds, more at home support for seniors, and better sick benefits for workers, especially in seniors care?

There are often reasons why individuals may not be capable of making “the right decision”, or simply that their circumstances force them into difficult life decisions.

A senior may move out of their home and into a long-term care facility because the family simply cannot afford private at home nursing care.

Individuals will take precarious work, casual work, and temporary work because the kinds of permanent full time jobs that come with sick benefits may not be available. This is especially dangerous when these are the same staff working at seniors communities.

Freeing up our hospitals

Photo by Levi Meir Clancy on Unsplash

Our hospitals are best equipped to handle acute health problems. They are not set up to deal with many of the chronic conditions that show up every day in their departments.

Diabetes mismanaged can lead to hospitalization, as can heart disease, and mental health disorders. More support for chronic disease management in community can shift the overall risk of hospitals becoming overwhelmed opening up our hospital to acute care interventions.

So, individuals can help to “flatten the curve”, and public policy can “shift the mean”. In either case, our common welfare must come first.

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