What Is the Prognosis for President Trump?

After dismissing the threat of the COVID-19 pandemic for months, President Trump announced on Twitter late Thursday night that he and his wife, Melania, had tested positive for the coronavirus that causes the disease. The White House on Friday said Trump is experiencing “mild” symptoms and that he will work from Walter Reed hospital “for the next few days.”

On KQED’s Forum radio program Friday, Dr. Bob Wachter, chair of the Department of Medicine at UCSF, spoke with host Michael Krasny about the prognosis for Trump, what therapeutics may be available to him, and an assessment of the president’s response to the pandemic from a public health perspective.

The following has been edited for length and clarity.

What is the prognosis for someone of President Trump’s age, height and weight, and other characteristics?

Bob Wachter: As we go through the checkboxes of what would give you a worse prognosis, he checks off many if not all of them. Older is worse than younger, and once you get up to 74 years old, your chance of dying is somewhere around 100 times greater than if you got it in your 20s. But his chances of survival are quite good; from what we know from public information, his chances of dying are about 1 in 20, though that’s probably about 10 times greater than the average person who gets COVID.

Men do almost twice as poorly as women for reasons that aren’t fully understood. He also meets the clinical definition of obesity in terms of his body mass index. That makes his prognosis three times worse than if he wasn’t obese.

Whatever other illnesses he has, and they have not been forthcoming about his medical record, that can only add to the negative prognostic signs. He already comes into this with a fair number of points against him.

That doesn’t mean he’s likely to do poorly, but the fact that he has symptoms means that he already is not in the best category: About 40% of people who get the coronavirus are asymptomatic through the entire course of the illness; maybe a little bit less than that because some are presymptomatic.

You might say, “the symptoms are mild.” Is that reassuring? I would say not at all. Because he gets tested every day, we know he only got it a couple of days ago. So he’s very early in his course. It would be highly surprising for him to be worse than just mildly symptomatic now. And his period of greatest risk will come in the next seven to 10 days or so.

What therapeutics is President Trump eligible for? Which ones do you think would help?

There is no proven treatment for early COVID in terms of preventing the illness from getting worse and leading to a shortness of breath or hospitalization or ultimately respiratory failure.

The only treatments that have been approved are ones that we know work for sure, and they’re only given for patients who are sick and are in the hospital. One is an antiviral drug called remdesivir, generally only available to people who are already sick and in the hospital. The other is an anti-inflammatory medicine called dexamethasone, which is a form of steroid.

There’s a set of therapeutics, which have shown promise in early studies, called monoclonal antibodies. They’re essentially an artificial form of antibodies. It’s very expensive, so it won’t be widely used, but giving it to people before they’re sick enough to need to be hospitalized — and it’s too early to be sure about this — lowers the rate of hospitalization and sickness. My guess is that they will figure out a way to get the president one of those drugs, even though it’s not generally available to the public.

There was a lot of discussion on Twitter last night about how even though he’s got these negative prognostic signs — his age, his obesity and being male — he’ll also get the best care in the world.

That might make a difference if it turns out these drugs work and he has access to them, whereas the rest of us wouldn’t. But I can tell you that in my experience and in the literature, there’s no great evidence that VIPs do better. And actually, sometimes they do worse because as you remember from Steve Jobs, sometimes they dictate their own care and it’s not evidence-based. Sometimes the care is somewhat chaotic because everybody is falling over themselves to take care of the patient. And so in terms of the VIP stuff, I wouldn’t think that his odds are any better than the average patient coming into the emergency room at UCSF today.

Can you talk about the rapid tests they use at the White House?

They are getting better. A new one has just come out, but I don’t think it’s being used yet at the White House. They do have false negatives.

It’s unusual, but there have been false positives with that test as well. It happened with Gov. [Mike] DeWine of Ohio. And so the first positive test that came back from the president last night might’ve been the rapid one. But by now, though they’re really not being transparent at all about this, because we could use a lot more information about the test, I assume he’s had the better, PCR test, and that both tests were positive. I don’t think they would have come out publicly unless they confirmed both tests.

I think part of the theme here is that in the environment of the White House, where people were being tested every day, they took that, I believe, as reassurance that nobody around the president could have COVID, and it’s OK, therefore, not to follow the public health guidelines. And that clearly was a mistake.

Joe Biden’s test came back negative. Could it be too early, though, for the test to be definitive?

The answer is yes. So it will be important that he has follow-up tests. It takes a few days of incubation period for the virus to replicate enough in order to have a positive test. So if the vice president’s exposure was through the debate, having a negative test today is certainly more reassuring than a positive test, but he would not be out of the woods. You’d want to see tests for another several days.

Biden’s risk should be extremely low. First of all, he’s been extraordinarily careful for the entire time. In terms of the debate itself, I didn’t see a measurement, but it looked like he was standing 15 to 20 feet away, which is generally, although not 100%, a safe distance.

What effect do you think this will have on the next planned debates? The next one, conducted in a town hall format, is scheduled for Oct. 15.

I think they’ll pay more attention to the risk of the virus in any kind of public gathering, so I imagine the rules will be somewhat different in terms of additional spacing. And certainly everybody in the audience will wear masks.

You know, it’s a little bit hard to say in terms of future presidential debates, because the president has symptoms now. In general, we say that two weeks after the onset of symptoms, you are no longer infectious, even if you are continuing to test positive.

In the beginning, we saw people with persistently positive viral tests for weeks and weeks and wondered if they were still infectious. And the evidence is really quite clear that a couple of weeks out, you’re no longer infectious, even though you may still test positive because you have the virus.

But certainly for the next two weeks, the president needs to be in absolutely strict quarantine. It would be public health malpractice to do an in-person debate within a couple of weeks of someone developing the coronavirus.

In a study released this week, Cornell University researchers found that President Trump is “likely the largest driver” of COVID-19 misinformation. What has been the president’s effect on public health? 

We can feel sympathy for the person and still feel like this pandemic has been mishandled at a national level. And the source of much of that is the president; there’s just no two ways about it.

It’s very hard to look at his responses all the way through and see anything good about them. Really, under any estimate that I can come up, with that has cost tens of thousands of lives.

We look at San Francisco, which just had its 100th death last week from COVID. If the entire country had our death rate, we would have had 165,000 fewer deaths. In San Francisco, our bodies are exactly the same, and the virus is exactly the same. But in an area where there was good political leadership and where the people wore masks and paid attention to the science, that is the kind of difference that could have been made.

I believe that had there been presidential leadership, as I think we would have expected — coming out early saying this is serious, here’s what you need to do, the kind of thing that he obviously knew about according to his discussions with Bob Woodward — I believe that we would have had tens of thousands if not 100,000 or more fewer deaths.

I try to be fair and say this would have been bad under anyone’s watch. It would’ve been a major challenge to the system, and people would have died. But it didn’t have to be like this and doesn’t have to be like this.

You know, as people have mapped out and gamed out what a pandemic would look like over the last 20, 30, 40 years, there was no scenario in which the federal government would have become part of the problem, would have been the source of misinformation, would have shackled the main agency responsible for prevention and educating people about what to do. That was not on the list of things that we needed to worry about.

What effect do you think President Trump’s contracting the virus will have on public health going forward?

If there’s any good that comes out of this, it will be that people who did not take this seriously will take it more seriously. You know, if the president can get it, anybody can get it.

There sometimes is this feeling that we’re out of the woods. It’s just clearly not true. The virus hasn’t changed in a material way over the course of eight or nine months, and neither have we. We are all susceptible.

What’s remarkable is we know the things that one needs to do to lower your chance of contracting the coronavirus. And unfortunately, the president has doubled down on not doing those things. Obviously we wish him well. But there was a lot of foolish behavior that went into this.

A lot will hinge on how he does. If he has a mild case, he may feel a little bit crummy for a few days or a week or so and be back to normal. And you wonder what will come out of the politics of that if he recovers. There is also a decent chance that he will do poorly.

Can we say that this finally puts to rest the idea that hydroxychloroquine can indeed be a prophylactic? The president took it for weeks and swore by it.

What puts that idea to rest is the fact that there have been more than a dozen studies on that question. But no, I think it’s hazardous to use single-case patient examples. That’s part of what gets the president in trouble: He sees a case where the patient miraculously got better. And the next thing you know, he’s touting it as a cure. That’s why we need science. The fact that he may have been taking hydroxychloroquine and he still got sick is interesting, but to me not persuasive. What’s persuasive is that it has been massively studied, and the evidence is quite clear that it does not work.