The ‘irony of the day’: Covid-19 at the White House is a simple matter of workplace transmission

President Trump’s news via Twitter early Friday that “@FLOTUS and I tested positive for COVID-19” came as a surprise and shock to some, but was a just-a-matter-of-time event for others.

I reached out to experts around the U.S. for their perspectives on Covid-19 transmission at the White House, caring for celebrity patients, and caring for geriatric patients with Covid-19. These conversations have been lightly edited for continuity and clarity.

• Sandro Galea: A simple matter of workplace transmission
• Barron H. Lerner: The patient wants the illness spun a certain way
• Anna Chodos: I try to reassure older patients that Covid-19 is not a death sentence

Sandro Galea

This is indeed the irony of the day. That the president and first lady have tested positive for the coronavirus — and of course it remains to be seen how ill they will become from it — should first be seen as a simple matter of workplace transmission. At one level, the White House is a workplace like any other. From all accounts, it wasn’t one that took seriously testing precautions, physical distancing, masks, and contact tracing. That several people who work in the White House contracted coronavirus shouldn’t come as a surprise.

On top of that, the president and his staff travel frequently and have contacts with large numbers of people, many of whom also aren’t taking the pandemic seriously. This occupational transmission is entirely consistent with what we have been seeing at the public health level: If you don’t take the precautions seriously, then you’re at higher risk of getting sick.

There’s also a more meta question about what it means for the moment we are in. I am waiting with bated breath to see the narrative the president gives to this story if he remains asymptomatic or develops only a mild case. If he is consistent with his previous narratives, it’s likely he will say it was not a big deal. Of course, he has shown himself perfectly capable of not being consistent previously with his previous narrative, so we’ll have to wait and see.

A third thing that comes to mind is the impact of this infection on the future of the republic. If the president gets sick, will that fuel his unfounded charges that the election is not going to be a fair one, since he got sick at the end? It would be tragic for this to allow him to cast doubt on the outcome of the election if it does not go his way.

Sandro Galea is a physician, dean of the Boston University School of Public Health, and chair of the board of directors of the Association of Schools and Programs of Public Health.

Barron H. Lerner

Taking care of a celebrity or VIP patient, like the president of the United States, can be a challenge.

Until relatively recently, it was ironic that important people often got poorer care than “regular” people. The doctors involved tended to stray from their normal medical protocols, due to their anxiety about treating a high-profile patient or by bringing in other doctors who may not have been needed. Some did too many tests, just to be on the safe side, and others didn’t do enough because of issues of comfort and privacy. There have been many notable cases of terrible care for VIPs. One of the best-known recent examples is the care of Michael Jackson, who died from a powerful anesthetic either administered or prescribed by his physician.

At some point the phenomenon began to draw attention. There was even the obligatory article about it in the New England Journal of Medicine in the late 1980s. People began creating strategies that focused on giving the patient the best medical care. The ways to guard against VIP syndrome are pretty logical: Put a specific person in charge of the case. Don’t order unnecessary tests. Care for the person the same way you would if he or she wasn’t famous. The effort now is to make hospitalization or outpatient treatment as normal as possible for everyone, including VIPs.

Handling the flow of information can be especially tricky, especially with patients who are politicians. They generally try to dictate what will be said publicly, which can back a doctor into a corner. The patient wants a specific story told, or the illness spun a certain way. Doctors can run into situations in which they feel obliged — or even bullied — into doing something they ordinarily wouldn’t do or saying something to the press they normally wouldn’t say.

The public, of course, never learns everything. They will still get only the crafted narrative that the patient and doctor have agreed upon. The gap between the real medical situation and what the public is told might be even wider with someone like President Trump, who has a reputation for not always telling the truth.

Barron H. Lerner is an internal medicine physician and historian of medicine in the Division of Medical Ethics at NYU Langone Medical Center and author of “When Illness Goes Public: Celebrity Patients and How We Look at Medicine” (Johns Hopkins University Press).

Anna Chodos

The first thing I think about with my older patients who have been diagnosed with Covid-19 is that they’re probably really, really scared, because the misleading messaging about this disease is that it kills all of the older people who get it. So the first thing I try to do is remind them that even though older people have a higher likelihood of serious illness, most survive and may even do fine throughout. That is true for people in their 80s, 90s, and 100s. A diagnosis of Covid-19 is not a death sentence for older people.

My job as a clinician is to support my patients and let them know what support is available. For them, emotional support is an important part of care because of the fear machinery around this disease.

This is a public health issue and we are all in it together. Yet it’s been argued very publicly that if we just shut away older people from society, we can wait this thing out until we get a vaccine.

That doesn’t make sense to me. I’m in my 40s. I fear getting this virus. Who knows what the outcome could be? You could sail through it or be someone who has a prolonged course. You could develop prolonged neurologic side effects, such as the brain fog symptoms people have described. The reverse and unintended consequence of the messaging that only older people and people with underlying conditions are at risk of bad outcomes from Covid-19 is blasé attitude among younger people that nothing will happen to them.

However, the clinical care for an older person with Covid-19 isn’t necessarily different from that for a younger person. What’s needed is age-friendly care in general.

One-third of older Americans live alone. Among those 80 and older, 30% — and that’s a low estimate — have dementia. We have to pay attention to how we are reaching out to older patients and checking in with them. Do they have a caregiver? Is the caregiver still coming or did they stop because of Covid-19? Do they have food? The medicines they need? If you’re lucky, you can mobilize resources to do in-person or home check ins. With Covid-19, people with mild symptoms can decompensate very quickly, so making sure they are able to access emergency care quickly is important.

My guess is that’s why President Trump’s doctors sent him to the hospital. It’s an “abundance of caution” as someone called it. He’s also getting certain treatments that need to be administered in the hospital.

If we could do that for everybody, fewer people might die because of Covid-19.

Anna Chodos is an internal medicine physician and geriatrician in the Division of Geriatrics at the University of California, San Francisco.