In the year 2020, in the midst of a global pandemic with the leader of the free world hospitalized, the glow of democracy fading, and winter coming, medical professionals in the United States faced an uncomfortable new reality…..they were being co-opted to serve as propaganda tools for the state…..

Political interference in the US’s public health messaging began early in the covid-19 pandemic, and continues, in the form of watered-down, manipulated, contradictory, and misleading covid-19 guidance from the Centers for Disease Control, the US Food and Drug Administration (FDA), and Department of Health and Human Services. Unsettling events during this past week shed new light on how dangerously advanced this has become. 

After months of flaunting basic public health measures including not wearing masks and holding large gatherings, Donald Trump, the president of the United States, was infected with SARS-CoV-2 and, while still contagious, went for a limo ride and then returned to the White House. This presumably happened with the approval or at least acquiescence of medical doctors at Walter Reed Medical Center and/or the White House physician. We have not heard otherwise. But Trump’s actions have been met with widespread criticism and no knowledgeable self-aware medical professional thinks these actions are justifiable. 

Medicine is more than a means to an income—it is a profession. It has a code of conduct critical to its mission of unconditionally improving the health and wellbeing of the people it serves. In the act of that service, doctors are privy to intimate details of individuals’ health that must be protected from disclosure. There were two acceptable approaches to the press briefings given by Sean Conley, the physician to the president, to update the public on the president’s health. The first approach would have been to report that personal health information can only be released with the patient’s consent, the president has not consented, end of briefing. In that scenario, the president’s health becomes a national security issue for the cabinet and the leaders of Congress. The second approach, with consent, is full disclosure of basic medical information, medications, vital signs, test results, and general status without editorial comment. Instead, Conley released bits and pieces of information in odd parcels without responding to the press. Physicians experienced in covid-19 management know the information provided was cherry picked to fit a political narrative about “not being sick” as there is no other plausible explanation. Doctors should never manipulate facts to serve politicians. 

Based on reports from Mark Meadows, the president’s chief of staff, Trump was not well on Friday 2 October, and apparently had a fever and, at least transiently, low oxygen saturations. He was transferred to Walter Reed Medical Center that day so there is no reason to doubt Meadows’ statement. 

Typically, patients hospitalized with covid-19 have an exposure, the virus replicates asymptomatically for 3-5 days, they may then experience non-specific fatigue, low grade fevers with development of a dry cough, followed by true fevers with hypoxemia developing in 1-4 days. Based on what we’ve been told, the president was likely infected sometime between 23 September and 27 September, and will likely be infectious through to the 12 October, or thereabouts. With regard to therapeutics, the president is reported to be on famotidine and zinc, which will pass without comment. He is said to have received 8 gm of REGN-COV2, a cocktail of two neutralizing monoclonal antibodies that bind the SARS CoV-2 spike protein receptor binding domain (RBD) at noncompeting sites [1]. According to a press release by Regeneron on 29 September, in an ongoing phase I/II/III clinical trial 8 gm of REGN-COV2 reduced the SARS CoV-2 viral load by 0.6 logs (4-fold) and reduced symptoms most effectively in subjects who were SARS CoV-2 antibody negative [2]. On Wednesday 7 October, Trump announced that he plans to make the antibody cocktail free to anyone who needs it, even though as yet it does not have FDA approval. 

In delayed fashion, we learned that the president was on remdesivir. Remdesivir does not affect the viral load [3], but a five day course of therapy may decrease the time to recovery in intubated patients, for reasons that are not yet clear [4].  And finally, in delayed fashion, which adds further weight to the thesis that the information released was cherry picked, we learnt that the president was on dexamethasone. The use of dexamethasone supports the president’s room air oxygen saturation on 2 October dipping below 94%. In the Recovery Trial, dexamethasone had a survival benefit only in individuals requiring oxygen supplementation. Patients on dexamethasone without hypoxemia tended toward worse outcomes, even death [5]. 

While the post-hoc sleuthing to piece together clinical events is interesting, the real issue facing the medical community is that serious political pressure is being brought to bear on medical professionals in the United States. What’s worse is that many of them appear to be giving in to it, an outcome that will have negative consequences for the reputation of the medical profession and for controlling the covid-19 pandemic.  

Raymond Johnson, associate professor of medicine and of microbial pathogenesis, Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine 

Competing interests: None declared

References:

1. Hansen J, Baum A, Pascal KE, et al. Studies in humanized mice and convalescent humans yield a SARS-CoV-2 antibody cocktail. Science 2020; 369:1010-4.
2. Regeneron. Press Release. https://investorregeneroncom/news-releases/news-release-details/regenerons-regn-cov2-antibody-cocktail-reduced-viral-levels-and 2020.
3. Wang Y, Zhang D, Du G, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2020; 395:1569-78.
4. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 – Preliminary Report. N Engl J Med 2020.
5. Group RC. Effect of Dexamethasone in Hospitalized Patients with COVID-19 – Preliminary Report. medRxiv 2020.