What lessons should we learn from the fact that the president of the United States has caught Covid-19?
There is one simple one, which the novel coronavirus, SARS-CoV-2, keeps teaching but which seems extremely difficult to learn: There are no magic bullets against Covid-19.
No single strategy or technology is going to rescue society from the pandemic: not masks, not better testing, not a drug, not vaccines. For any of these, it’s easy to get caught up in optimism and hope. But the reality is that fighting the coronavirus requires doing many things correctly.
That hasn’t stopped people — President Trump among them — from grasping for single, easy solutions. In March, Trump tweeted that hydroxychloroquine, given with the antibiotic azithromycin, could be “one of the biggest game changers in the history of medicine.” They were not. He said the virus would miraculously disappear with warmer weather. Outbreaks have continued. And lately, he’s been betting on a vaccine, saying it could even come before “a very special date,” meaning Election Day.
“The entire pandemic has been about magic bullets,” says Ashish K. Jha, dean of the Brown School of Public Health.
But we’re not taking down this enemy with a single shot. Instead, everyone has to become an oddsmaker — or a military commander — trying to minimize the chance that the virus will breach their defenses.
The strategy of protecting the White House was a clear example. To keep the president safe, everyone who might come into contact with him was given a rapid test for SARS-CoV-2. But, as STAT reported in April, the test was thought by many outside experts to miss some infections. More than that, any test would miss some infections. No test is going to catch every case of SARS-CoV-2 every time. Every test has false negatives.
Yet the White House apparently viewed a positive test result as carte blanche to behave as if SARS-Cov-2 didn’t exist. At the Rose Garden event announcing the president’s Supreme Court pick, attendees hugged, shook hands, and gathered inside as if a negative test result offered complete safety. There were few masks in sight.
In contrast, broad public health strategies against the virus that rely on testing — such as proposals from the Rockefeller Foundation or the proposal championed by Harvard Professor Michael Mina in which the country is flooded with cheap, less accurate tests — don’t put such faith in a single test. The idea is that testing often, and catching cases when you can, will reduce the number of times healthy people are exposed to infected ones. Like everything else with Covid-19, it’s an odds game, and debates over any strategy’s utility are arguments about those odds.
The same is true of masks. Robert Redfield, the head of the Centers for Disease Control and Prevention, testified to Congress last month on their benefit: “These face masks are the most important, powerful public health tool we have,” he said. Nobody knows exactly how much protection a mask provides. That’s part of why some experts were skeptical of masking early in the pandemic. But evidence from studies of the physics of transmission and disease spread in countries with different policies on masking have now led to near-universal agreement that masking is a good idea. They reduce the odds of the virus spreading.
But you wouldn’t bet on masks without testing — or testing without masks. Or either without social distancing. It’s not that there is something special about keeping six feet apart from people — some coughs may spread coronavirus farther. But if everybody stays six feet away, the odds of transmission go down.
And then there are vaccines. “People are placing hope in the idea that a vaccine will allow us to go back to normal,” said C. Michael Gibson, a Harvard cardiologist known for his ability to analyze trial data. “I think that’s false hope.”
It’s not that the vaccines in development won’t work, or that a vaccine won’t be a key tool in combating the virus. But we could end up still needing masks sometimes — or at least we won’t be back to shaking hands.
At least three vaccines — from Pfizer/BioNTech, Moderna, and Johnson & Johnson — are likely to have results later this year or early next. And there are many more in testing behind them. It’s not unlikely that at least one, and possibly several, will be effective enough to work.
But a vaccine could be approved if it reduces symptomatic cases of Covid-19 by just half. And whether it reduces transmission of the virus, or just keeps people from getting sick, is another open question. What’s more, all of the vaccines may be unpleasant to take — they can cause fevers, fatigue, and other side effects — and hard to distribute. The Pfizer shot, in particular, needs to be kept at temperatures much colder than an ordinary freezer.
A vaccine that didn’t slow the spread of the virus but meant fewer people ended up in the hospital would still be useful. And there is every chance some of the vaccines may outperform this bar. But even several great vaccines probably don’t turn off the pandemic like a switch. Jha said that he has advised the Biden campaign that if he wins, they will be dealing with the pandemic well into the next presidential term.
Dealing with that means not jumping the gun. Searching for a magic solution can leave you worse off than if you did nothing. Look at the case of hydroxychloroquine. Even those who think the drug has some benefit, perhaps in preventing the disease, should be able to see from the data from several randomized studies that the way it was used during March and April, in hospitalized patients, was wrong. It is simply clear it did not help.
What’s required now to return to a more normal life is the same thing that has been required all along: a series of incremental strategies (pushing testing, requiring masks, developing vaccines and treatments), and clear priorities (do you want to open schools or bars?) driven by an informed public debate about what matters to society.
As H.L. Mencken famously said, for every complex problem, there is an answer that is clear, simple, and wrong. What’s required here isn’t Rambo-style heroics. It’s clear strategy, and the kind of courage and patience under fire that soldiers in the American Revolution needed when they were told, “Don’t fire until you see the whites of their eyes.”