COVID-19, caused by a Sars-Cov-2, has led to a pandemic that threatens everyone everywhere all around the world. Most people till now are familiar or likely heard the phrase “flatten the curve” and perhaps even seen the multicoloured graphs online or on TV debates but not  so much is discussed about “Raise the Line” [1-2]

While healthcare and government leaders around the globe are focused on “flatten the curve” to slow down the spread of COVID-19, an emerging concurrent cry to “raise the line” of healthcare system capacity is also being showcased everywhere around the world. The best strategy to limit the damage all over the globe and to beat this pandemic is to combine the both. Data from all over the world also reveals that there is a need to “flatten the curve” &‘raise the line’ in order end the current coronavirus outbreak and safe more lives [3-4]

What does that mean, and how does it works? Let it be explained! The curve everyone's talking about or heard is the projection of the number of people who will suffered from COVID–19 over a period of time. The graph represents the number of people who have the COVID-19 disease, on the y-axis (vertical), for each day since the first case, on the x-axis (horizontal). In short, this is a graphic depiction of the number of new cases by date of onset of the disease [5-6].

The overall shape of the curve reveals the type of outbreak we’re dealing with and the horizontal line represents the health care system capacity (beds, doctors, staff and PPE, Ventilator etc.). A high curve is created by a steep increase in the number of cases per day followed by a quick decrease. A flatter curve is created by a more gradual increase in the number of cases per day and a more gradual decrease [7-8]. 

Why does this matter? Well, there are a limited number of doctors, hospitals, beds, PPEs and even test kits in the India. The health care system of India has a fixed capacity of the number of patients it can treat per day, which is marked by a straight line on the graph. A higher curve would likely exceed that health care capacity, meaning that people would be left waiting for days to be seen and treated by medical professionals in the hospitals. The flatter the curve, the more likely it is to fall under that maximum health care capacity, allowing each patient access to the health resources they needed [7,9].

Now, most hospitals in the India and many other countries are already operating close to the capacity line, so when lockdown restrictions will be eased out, the infectious agent Sars-Cov-2 spreads very rapidly, and the curve can rise and may cross the line.  When this happens, the healthcare system of India can no longer meet the needs COVID-19 patients as well as all of the other types of chronic ill patients like cancer patients, diabetic, hypertensive and other co morbid conditions. At that point, people will not get the best care and outcomes like the mortality and morbidity rate will start to rise quickly [10-11].

For these reasons, a large number of lives can be saved by simply ensuring people get infected at a slower rate, and this is called “flatten the curve”.  A flatter curve assumes the same number of people ultimately gets infected, but over a longer period of time, which leads to a less overwhelmed health care system. Over a long period of time, the number of people infected with the novel coronavirus might be about the same, but the key difference is in the number of cases each day [12-14]

So what we need to do is flatten that down? We can do that by trying to interfere with the natural flow of the outbreak of COVID-19. That’s where social distancing plays a role; which refers to measures aimed at reducing close contact between people.  It involves avoiding people or places where it’s possible to come in contact with germs by droplets, direct contact or surfaces that are potentially contaminated with the virus. By limiting interactions between individuals, we can limit the spread of the disease.  Apart from social distancing, there are a number of key behaviours that we can do, like practicing good hygiene by washing hands frequently and cleaning or disinfecting frequently touched objects and surfaces, and isolation in confirmed and suspected cases of COVID-19 and all other precautional measures that will help in slow down the spread of the virus over time [13,15-17]

Does flattening the curve work? Our objective right now was not to eradicate the disease, but to delay the peak of the pandemic, decompress the burden on hospitals and health infrastructure and diminish the number of overall COVID-19 cases and the severity of its impact on health system. Non-pharmaceutical interventions such as hand washing, social distancing, isolation and disinfection reduce the daily infections, therefore helps in flattening the epidemic curve. A successfully flattened curve spreads health care needs over time and the peak of hospitalizations under the health care capacity line. Practicing social distancing to flatten the curve can buy that the precious time without overwhelming our health care systems [5,18-20]

Flattening the curve may still result in the same number of people being infected but means that it will happen over a longer period of time, allowing the healthcare system to plan ahead for a future influx of patients [21].

The graph-1 shows the effects that social distancing will help in decreasing the main spike in cases across a longer period of time.  The whole notion of flattening the curve is to slow things down so that this doesn’t hit us like a brick wall [21-22]

Figure image is available in PDF Format

Figure -1: CDC graphic on flattening the curve (CDC Photo) ³²

Is only flattening of curve sufficient? Yet the line for hospital capacity (Figure-2) still sees a significant chunk of this peak lying in the danger zone even after flattens the curve where the healthcare system will not have an adequate number of resources to treat patients [23-24].

Figure image is available in PDF Format

Figure -2: CDC graphic on Raising the Line (CDC Photo) [25]

Social distancing flattens the curve but the line shows that the healthcare system capacity still falls under the peak of the outbreak meaning more staff, beds, medicines, PPEs and  other supplies are needed. It is still expected that 20 percent of those infected will need hospitalization, leaving healthcare experts warning that the line must be raised at lightning speed to ensure patients can be properly treated [23-24].

Data from all over the globe shows how the country’s healthcare system capacity must also be increased hand in hand with flattening the curve so that more lives will be saved from coronavirus epidemic. It then shows how increasing this hospital capacity and ‘raising the line’ can bring the full peak of the outbreak under the critical line and save many lives [8,25,23]

The healthcare system must  ‘raise the line’ to save thousands of lives, working alongside social distancing and  healthy behaviour changes  to ensure that waves of patients of COVID-19 in the future can be treated. Increasing capacity doesn’t just mean more masks, beds, ventilators, or medicines for the 20 percent of cases expected to require hospitalization. It also means diverting resources to the least-resourced areas, training more health care staff to work in the ICU, and ramping up telemedicine for non-Covid patients to free up hospital beds [25,8,23]

The battle comes as the India has fewer hospital beds, fewer doctors and fewer nurses than other rich countries. Hospitals, especially in rural areas where resources are more limited, must raise the capability of their facilities to deal with future waves of patients with increased staffing and beds [7,19,26,].

“Raise the line” requires an extraordinarily rapid mobilization of resources (humans, money, and equipment), ingenuity and flexibility, and leadership and coordination. It’s on all of us: the center, state, and local government; the army; hospital leaders and staff; the private sector; and even the general public to support our health care staff now [25,8,1].

How the General Public can Help? [27]

• Stay at home

• Practice social distancing

• Remember to wash hands frequently 

• Great everyone with wave or “Namaste”, No handshakes, No hugs. 

• Avoid going out except for essential basic needs like grocery and medicines.

• Keeping at least 6 feet space between you and others whenever you are market places, grocery stores, daily utility stores, public places, govt. offices, banks, electricity or water bill counters, post offices, health care settings, at any public place per se; till the pandemic subsides. 

• Maintaining a strategic distance from social affairs of in excess of 10 individuals and other crowd. 

• While meeting somebody outside of your family unit, attempting to stay separated at least 6 feet. 

• Stay away from close contact with somebody who is sneezing or coughing. 

• Significantly limit your face-to-face interaction with friends and relatives, if possible.

• Stay in contact utilizing other mode of communication like telephone, web, and online networking.

• Make masks for frontline workers

• Ensure that medical supplies like N95 masks are being used only by healthcare providers only.

• Use telemedicine facilities for a routine check-up.

• Reschedule elective surgery.

• Stay out of hospitals unless absolutely necessary

• Most importantly - don’t panic! 

These steps will reduce the number of people in hospital but also reduce the risk of being infected when they do by stamping out new chains of transmission, 

What government can do? [27]

• Increase staffing by bringing back retirees health personals and allowing early graduation from medical and nursing schools.

• Increase the number of Hospital beds and staff.

• Increase supplies including face masks, medicines and other personal protective equipment.

• Doctors and nurses from less affected areas could be transferred to more affected areas.

• Strict implementation of lockdown or curfew.

• Cancelling large public gatherings. These measures includes banning concerts, sporting events, and other mass gatherings, closing movie theatres, telling people who can telecommute to work from home, and potentially closing schools.

• Cancelling flights and other public transport.

What hospitals can do? [27]

• Within hospitals, every effort is made to keep patients with COVID-19 separate from patients who are hospitalized for other reasons in order to avoid intra-hospital spread. 

• To keep clinicians safe, they must use personal protective equipment like N95 masks, and since they’re in short supply it’s important that they’re only being used by healthcare providers.

• Training for COVID-19 — medical residents, pharmacists, nursing students, paramedics, EMTs, and more

• Discharging healthy patients from hospitals as quickly as possible

• Cancelling elective procedures and ramp up staffing

• The supplies of protective equipment should remain adequate throughout the pandemic.

• Health care providers should figure out ways to provide online health education opportunities.
• Health care providers should see patients with home care and telemedicine.

Some hospitals are already raising the line; many hospitals are rapidly trying to build up capacity so they can handle a coming surge in Covid-19 patients, others are struggling and need help from state and central government. Many States are already setting up field hospitals (like tents in big Parks and stadiums) and converting existing buildings (like dormitories/hotels) into temporary medical facilities. That is a necessary step just to make sure there are enough beds for Covid-19 patients, and to keep other patients routed away from the hospital to prevent further infection. These plan comes with plenty of logistical challenges or funding issues, but the goal is to lift the line [1-7]

Ultimately, the most important factor in current scenario is to avoid overwhelming the healthcare system is to keep the curve below the capacity threshold, ensuring the increased demand doesn’t exceed the available resources. Yet the focus on the current increasing numbers of COVID-19 patients day by day and long-range predictions may obscure something else: but the India still has an opportunity to save thousands, even tens of thousands, of lives in the coming days, weeks, and months [19,28-29]

To do so, we have to the slow down the rate of transmission by staying home: flattening the curve with social distancing to relieve the pressure on the health care system. But to save more lives nationwide, we must also raise the capacity of the health care system at lightning speed so there’s more lifesaving care for the patients who will develop severe Covid-19 illness in the coming weeks and months [1,21,30]

In conclusion ,By flattening the curve, the peak of hospitalizations is lessened, softening the burden on hospitals with a lower surge in patients, but in order for the fight against the outbreak  of COVID-19 to be fully effective, we must also ‘raise the line’ by increasing the capacity of  healthcare system. A combination of ‘flattening the curve’ and ‘raising the line’ will save thousands of lives in the coming months and allow for a swifter end to the outbreak and a return to normal life. We can fight the pandemic. If we follow some above said strategies, we all can fight and win over this situation. Most importantly, this time is not to be panic but it’s the time to unite together against the pandemic.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College and Hospital, Shimla.

1. Barclay, E., Scott, D., & Animashaun, C. (2020).  The US doesn’t just need to flatten the curve. It needs to “raise the line. Available at: https://www.vox.com/2020/4/7/21201260/coronavirus-usa-chart-mask-shortage-ventilators-flatten-the-curve. Assessed on 18 May 2020.

2. Entomology Today. (2020). Flatten the curve raise the line. Available at : https://entomologytoday.org/2020/04/29/making-great-scientific-figures-tips-for-entomology-students/20200410_flatten_the_curve_raise_the_line_-_pandemic_english/ Assessed on 20 May 2020.

3.  Jonas, S. (2020). Healthcare Leaders Highlight Need to “Raise the Line” of Healthcare Capacity In addition to “Flattening the Curve” of the Spread of COVID-19. Science news. 2020. Available at: https://sciencenewsnet.in/healthcare-leaders-highlight-need-to-raise-the-line-of-healthcare-capacity-in-addition-to-flattening-the-curve-of-the-spread-of-covid-19/Assessed on 19 May 2020.

4. Osmosis. Beating Corona virus: (2020). Flatten the Curve Raise the Line. Available at: https://www.osmosis.org/learn/Beating_Coronavirus:_Flatten_the_Curve_Raise_the_Line. Assessed on 18 May 2020.

5. Srikant, A. (2020). The hill. What does it mean to flatten the curve. Available at: https://thehill.com/changing-america/well-being/prevention-cures/487818-what-does-it-mean-to-flatten-the-curve-and-does .Assessed on 21 May 2020.

6. Detmer, W.M. (2020). Epidemic__Epi__Curves_for_Coronavirus. Available at:  https://relief.unboundmedicine.com/relief/view/Coronavirus-Guidelines/2355041/all/Epidemic__Epi__Curves_for_Coronavirus_COVID_19#4 Assessed on 18 May 2020.

7. Sharma, S.N. (2020). Coronavirus: Can India ramp up its health infrastructure swiftly to contain this pandemic? Available at:    https://economictimes.indiatimes.com/news/politics-and-nation/coronavirus-can-india-ramp-up-its-health-infrastructure-swiftly-to-contain-this-pandemic/articleshow/74866036.cms?from=mdr. Assessed on 22 May 2020.

8. Lopez, G. (2020). Why America ran out of protective masks — and what can be done about it. Available at:   https://www.vox.com/policy-and-politics/2020/3/27/21194402/coronavirus-masks-n95-respirators-personal-protective-equipment-ppe. Assessed on 24 May 2020.

9. Singh, P., Brahma, D., & Chakraborty, S. (2020). COVID-19 :Does India have enough doctors? An analysis of growing COVID-19 patients and existing medical capacity. 

10.  Bhatia, S., & Alexander, S. (2020). Covid-19 shows why we need a healthcare reboot for India. Available at: https://www.livemint.com/politics/policy/will-covid-19-prompt-health-reboot-11585497828527.html Assessed on 19 May 2020.

11. Devulapalli, S., & Dantewadia, P. (2020). India’s coronavirus curve has spiked up, cases could reach 10,000 in two weeks. Available at: https://www.livemint.com/news/india/mint-covid-tracker-india-s-coronavirus-curve-has-spiked-up-cases-could-reach-10-000-next-week-11585800843254.html Assessed on 18 May 2020.

12. John. (2020). Can We Discuss Flatten-the-Curve in COVID19? My Eight Assertions Available at : https://www.drjohnm.org/2020/05/can-we-discuss-flatten-the-curve-in-covid19-my-eight-assertions/ Assessed on 19 May 2020.

13. Roberts, S. (2020). Flattening the Coronavirus Curve. NYTimes Available at : https://www.nytimes.com/article/flatten-curve-coronavirus.html\ Assessed on 18 May 2020.

14. Ramesh, S. (2020). How to slow down COVID-19 — this is the only way to ‘flatten the curve’ of coronavirus spread. Available at:  https://theprint.in/health/how-to-slow-down-covid-19-this-is-the-only-way-to-flatten-the-curve-of-coronavirus-spread/383123/ Assessed on 20 May 2020.

15. Branswell, H. (2020). Why ‘flattening the curve’ may be the world’s best bet to slow the coronavirus. Statnews. Available at: https://www.statnews.com/2020/03/11/flattening-curve-coronavirus/ Assessed on 20 May 2020.

16. Calsyn, M., Gee, E., Waldrop, T., & Rapfogel, N. (2020). Social Distancing To Fight Coronavirus: A Strategy That Is Working and Must Continue. americanprogress. Available at: https://www.americanprogress.org/issues/healthcare/news/2020/03/25/482278/social-distancing-fight-coronavirus-strategy-working-must-continue/ Assessed on 21 May 2020.

17. Srivastava, V. (2020). How India can flatten the coronavirus curve fast. Natureasia Available at:https://www.natureasia.com/en/nindia/article/10.1038/nindia.2020.44 Assessed on 18 May 2020.

18. Wikipedia. (2020). Flatten the curve Available at:https://en.wikipedia.org/wiki/Flatten_the_curve Assessed on 23 May 2020.

19. Modern Healthcare. (2020). Coronavirus outbreak: 'We're not closing our country' if second coronavirus wave hits, Trump says Available at: https://www.modernhealthcare.com/safety-quality/coronavirus-outbreak-live-updates-covid-19 Assessed on 24 May 2020.

20. Lowyinstitute. (2020). Coronavirus-Pandemic. Available at:https://www.lowyinstitute.org/the-interpreter/debate/coronavirus-pandemic Assessed on 25 May 2020.

21. Geisinger. (2020). COVID-19: What does “flattening the curve” mean? Available at: https://www.geisinger.org/health-and-wellness/wellness-articles/2020/03/18/16/20/covid-19-what-does-flattening-the-curve-mean Assessed on 19 May 2020.

22. Meredith, S. (2020). Flattening the coronavirus curve: What this means and why it matters. Available at:https://www.cnbc.com/2020/03/19/coronavirus-what-does-flattening-the-curve-mean-and-why-it-matters.html Assessed on 18 May 2020.

23. Mulraney, F. (2020). Is 'flattening the curve' enough? Dailymail. Available at:https://www.dailymail.co.uk/news/article-8202529/How-needs-raise-line-flattening-curve-prevent-coronavirus-spread.html Assessed on 24 May 2020.

24. Gavin, K. (2020). Flattening the Curve for COVID-19: What Does It Mean and How Can You Help? Available at:https://healthblog.uofmhealth.org/wellness-prevention/flattening-curve-for-covid-19-what-does-it-mean-and-how-can-you-help Assessed on 18 May 2020.

25. Barclay, E., Scott, D., & Animashaun, C. (2020). The US doesn’t just need to flatten the curve. It needs to “raise the line. Available at: https://publicnewsupdate.com/the-us-doesnt-just-need-to-flatten-the-curve-it-needs-to-raise-the-line/ Assessed on 24 May 2020.

26. Krishna, D., & Rao, T. K. (2020). George .Ironing out wrinkles in India’s pandemic response Available at:https://www.thehindu.com/opinion/lead/ironing-out-wrinkles-in-indias-pandemic-response/article31156471.ece Assessed on 24 May 2020.

27. Srivastava, D. (2020). Flatten the Curve, Raise the Line and Beat the Corona Virus. Available at:http://adamasuniversity.ac.in/flatten-the-curve-raise-the-line-and-beat-the-corona-virus/ Assessed on 23 May 2020.

28. Specht, L. (2020). What does the coronavirus mean for the U.S. health care system? Some simple math offers alarming answers. Statnews. Available at:https://www.statnews.com/2020/03/10/simple-math-alarming-answers-covid-19/ Assessed on 23 May 2020.

29. Osmosis. (2020). Why You Should Pledge to RaiseTheLine During the COVID-19 Pandemic. Available at: https://www.osmosis.org/blog/2020/03/24/why-you-should-pledge-to-raisetheline-during-the-covid19-pandemic Assessed on 22 May 2020.

30. Godoy, M. (2020). Flattening A Pandemic's Curve: Why Staying Home Now Can Save Lives.The Coronavirus Crisis. Available at: https://www.npr.org/sections/health-shots/2020/03/13/815502262/flattening-a-pandemics-curve-why-staying-home-now-can-save-lives Assessed on 22 May 2020. https://www.brookings.edu/blog/up-front/2020/03/27/covid-19-does-india-have-enough-doctors-an-analysis-of-growing-covid-19-patients-and-existing-medical-capacity/ Assessed on 25 May 2020.