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I approached what to write about for SBM this Monday with some trepidation. My original plan had been to do a swift pivot away from COVID-19 for this week, given that the pandemic has dominated my blogging ever since March, but events made that increasingly difficult. Late Thursday night, I was working on a grant due Tuesday but that, because of my university grant office’s policy, had to be uploaded by early Friday afternoon, in order to give the university time to process it and submit it before the deadline, when I came across this Tweet being commented on in my Twitter timeline:

This came after the night before, when President Trump had Tweeted:

The next morning, as I scrambled from my home office to gather all the necessary documents, do the last minute proofreading and corrections necessary before uploading my grant application, and converting the many Microsoft Word Documents to the PDF format required, I could not help but be momentarily distracted from time-to-time by the rapidly moving story, as I felt compelled to check my Twitter feed at least once an hour. The initial reports were that President Trump and the First Lady had “mild symptoms,” but the situation rapidly evolved, with news reports leading many to question just how “mild” Trump’s symptoms were, although White House physician Dr. Sean Conley reported that Trump had developed fever, congestion, and cough by Thursday night.

Of course, as an obese 74-year-old male, President Trump is in a group at high risk for serious COVID-19 complications and even death, and doctors who treat coronavirus patients know that patients with initially mild symptoms can take a serious turn for the worse really fast, usually days after the onset of symptoms. Also, like many people, I was disturbed by the lack of Tweeting, as many have pointed out that if the President weren’t very sick, chances were that he’d have been Tweeting up a storm. The silence made us worry.

Then, late Friday afternoon after I had successfully uploaded all my files (albeit not without delays and last-minute complications), I learned that President Trump was being taken to Walter Reed Medical Center, where they have a Presidential suite. He definitely looked under the weather in the videos showing him walking from the White House to the helicopter, but not deathly ill. (Of course, if he were deathly ill, likely they would have transported him on a stretcher.) Around the same time, his Twitter account Tweeted this:

Again, he didn’t look entirely well in that brief video, but he didn’t look seriously ill, either, and he was obviously able to keep from coughing for the brief video and the walk to and from the helicopter. As the news accelerated over the weekend, by Sunday (when I’m writing this), I knew I had to comment, even at the risk of developments making my post outdated by the time it published on Monday. (That’s what addendums and updates are for, anyway.) The reason is that there are a number of SBM-related take-home points that this development tells us, the first of which every doctor knows: VIP care is not necessarily the best care. Other take home lessons include the observations that science matters, that masks and social distancing matter, and that being cavalier about them is a recipe for disaster.

Rosy political spin versus “everything but the kitchen sink”

It’s a well-known axiom in medicine that VIPs often get more care, not better care. Pretty much every doctor who’s ever taken care of a celebrity or other VIP knows that these patients tend to get more tests, more consults, and more interventions for the same condition than a non-celebrity non-VIP patient would. I can speculate about the reasons, but they seem to boil down to a perception of a much greater penalty for missing something or getting something wrong, combined with the desire of everyone involved to be near the celebrity, to be able to be seen as contributing something, and the higher level of entitlement and demandingness that many celebrities demonstrate. This is all in addition to the natural incentives always to “do more” in medicine compared to the relative lack of incentives to be more conservative and do less.

Indeed, I have written about this very conflict between the desire to “do more,” even if that “more” isn’t necessarily better, in our many posts about the phenomenon of overdiagnosis and overtreatment of cancer and other diseases. It’s not just screening, though. It’s treatment as well. It’s a trap that a lot of doctors fall into, one having gone so far as to blame The New York Times for having “killed” his patient with prostate cancer by publishing articles questioning the value of PSA screening for the disease. Moreover, patients love aggressive screening and treatment. They are very uncomfortable with “watchful waiting” and conservative measures. As I’ve written before, there thus exists a positive feedback loop in which patients want more aggressive screening, testing, and care, and physicians are rewarded because more aggressive screening and testing finds more problems they can “treat,” whether those problems really need to be treated or not. Then, as I’ve discussed, during the COVID-19 pandemic we have seen a phenomenon where science-based medicine has all too often been abandoned, with doctors bypassing clinical trials in the urge to “do something, anything,” even at the cost of abandoning the dictum, “First, do no harm.” Add this tendency to the most “VIP-est” of VIP patients, like President Trump, who’s already shown himself to be enamored of all manner of dubious treatments anyway for COVID-19, and you can imagine how this tendency would be magnified.

It is this very conflict that makes it so difficult to figure out what President Trump’s real condition is. Ever since Friday, news reports have alternated between glowing reports about how well he is doing with a drip-drip-drip of reports of the President receiving interventions that strongly suggest that he is considerably sicker than is being reported. It started with news reports on Friday that, while still at the White House before he was transported to Walter Reed, President Trump had received a dose of Regeneron’s experimental cocktail of monoclonal antibodies, plus, seemingly, everything but the kitchen sink. (Actually, not yet. The kitchen sink came later in the weekend.) From The New York Times:

President Trump has received a dose of an experimental antibody cocktail being developed by the drug maker Regeneron, in addition to several other drugs, including zinc, vitamin D and the generic version of the heartburn treatment Pepcid, according to a letter from his doctor that was released by the White House Friday afternoon.

Mr. Trump and the first lady, Melania Trump, announced early Friday morning that they had tested positive for the coronavirus. The president has a low-grade fever, nasal congestion and a cough, according to two people close to Mr. Trump.

In the letter, Mr. Trump’s doctor, Dr. Sean P. Conley, said “he completed the infusion without incident” and that he “remains fatigued but in good spirits.”

I’ve discussed the use of convalescent plasma before. It’s an old concept that involves harvesting pooled plasma from patients who have recovered from COVID-19 and using it to treat patients in the hopes that the antibodies raised by the patients who have recovered will fight the infection in new patients. Indeed, the FDA issued an EUA for convalescent plasma in late August, despite the lack of randomized controlled trial evidence that it works. The Regeneron product is not convalescent plasma. Rather, it’s a cocktail of two monoclonal antibodies directed at the main surface spike protein that helps SARS-CoV-2, the virus that causes COVID-19, attach to a receptor on human cells called angiotensin-converting enzyme-2 (ACE2):

The targeted region is dubbed the receptor binding domain. One antibody comes from a human who had recovered from a SARS-CoV-2 infection; a B cell that makes the antibody was harvested from the person’s blood and the genes for the immune protein isolated and copied. The other antibody is from a mouse, which was engineered to have a human immune system, that had the spike protein injected into it.

I’m not sure why they chose to do a mixture between human and a “humanized” mouse antibody, but that’s what the cocktail is. It’s been tested in 275 patients with COVID-19 who were asymptomatic or, at worst, moderately ill in a placebo-controlled trial and reported (although not yet in the peer-reviewed literature) to reduce the amount of virus in patients who were seronegative (had no antibodies to SARS-CoV-2) but to show little effect in patients who already had antibodies to the virus. Interestingly, the most dramatic drops in SARS-CoV-2 levels were seen in seronegative patients who had the highest levels of virus at the trial’s start. In any event, the idea is that the antibody cocktail might be able to prevent progression to severe disease in patients with mild disease who have not yet developed their own antibodies. The trial was not powered to show decreased progression to more severe disease in patients receiving the antibody.

I will admit that I was puzzled when I first learned that Trump had received the Regeneron cocktail, viewing it as an indication of more severe disease, but reading more led me to realize that he was probably an appropriate patient for this intervention, although we can’t know because the President’s viral load was not reported, nor was it reported whether he had detectable SARS-CoV-2 antibodies. The use of the compassionate use mechanism to get this product to the President also raised all sorts of ethical questions:

In an interview Friday afternoon, Regeneron’s chief executive, Dr. Leonard S. Schleifer, said Mr. Trump’s medical staff reached out to the company for permission to use the drug, and that it was cleared with the Food and Drug Administration.

“All we can say is that they asked to be able to use it, and we were happy to oblige,” he said. He said that so-called compassionate use cases — when patients are granted access to an experimental treatment outside of a clinical trial — are decided on a case-by-case basis and he is not the first patient to be granted permission to use the treatment this way. “When it’s the president of the United States, of course, that gets — obviously — gets our attention.”

Dr. Schleifer has known Mr. Trump casually for years, having been a member of his golf club in Westchester County.

And:

And:

Dr. George Yancopoulos, Regeneron’s president and chief scientific officer, said the company is already preparing for an expected influx of requests.

“This is certainly putting us in a difficult situation,” Dr. Yancopoulos said. The company is also planning for how to allocate the product if it is authorized for emergency use or approved. Regeneron has an arrangement with the Department of Defense to distribute the first 300,000 doses once it is available. “We didn’t want to decide who gets a limited number of doses,” he said.

Interestingly, the Regeneron cocktail was not administered under “right-to-try.” (Sorry, I couldn’t resist.) I also can’t resist saying that this is exactly the sort of thing that VIP medicine attracts, the use of the patient’s celebrity to gain access to treatments that others don’t have access to that might or might not be helpful. It could also be what led Trump’s doctors to give him an 8 g dose of the drug, when Regeneron’s own data show that 2-4 g is as effective as higher doses.

It wasn’t long before we learned more in the news reports, starting Friday night, when it was announced that he had received the first dose of a five day course of remdesivir. Remdesivir is an antiviral drug for which the existing data has most definitely not impressed me very much. In May Gilead Biosciences, the company that makes remdesivir, announced its results, rather than publishing them, and the results were not that impressive, but the FDA still issued an EUA for the drug for patients with severe disease. More results were published in July suggesting (but not nailing down) a reduction in mortality, and in August the EUA was expanded to all hospitalized patients with COVID-19, irrespective of their severity of disease. (Of course, if you’re hospitalized, you must have at least moderate disease or be in a group at high risk for complications.)

Then, as I was writing this post yesterday, the last (or maybe just the latest) shoe dropped:

To treat his Covid-19, President Trump has started receiving dexamethasone, a common steroid that has been shown to be helpful in people with severe cases of the disease but that doctors warn should not be used early in the course of the illness.

The announcement from Trump’s medical team Sunday morning that the president is on dexamethasone is sure to increase speculation about the president’s illness and was at odds with the generally upbeat description of his condition provided by his physicians. His doctors said Trump had not had a fever since Friday morning and did not have any shortness of breath. One even said that, if Trump “continues to feel and look as well as he does today,” their goal was for him to return to the White House on Monday.

Dexamethasone is generally reserved for patients who have serious disease. The National Institutes of Health’s treatment guidelines for Covid-19 say dexamethasone should be used only in hospitalized patients who are on ventilators or who require supplemental oxygen, and specifically “recommends against using dexamethasone for the treatment of Covid-19 in patients who do not require supplemental oxygen.”

These NIH guidelines are based on the RECOVERY trial, a multicenter, randomized, open-label trial in hospitalized patients with COVID-19, which showed a lower mortality among patients who received steroids (specifically dexamethasone 6 mg per day for up to 10 days or until hospital discharge, whichever comes first) in patients who require either mechanical ventilation or supplemental oxygen. In fact, the NIH panel that published the guidelines specifically recommended “against using dexamethasone for the treatment of COVID-19 in patients who do not require supplemental oxygen.”

So what’s going on with the President’s condition? His doctors’ reports have often been in conflict with other reporting regarding his condition. Notably, on Saturday, Dr. Sean Conley admitted that Trump had developed a fever, but stated that he had been “fever-free” for 24 hours and ducked and weaved regarding whether Trump had ever required supplemental oxygen:

But the briefing raises as many questions as it answers, specifically whether oxygen was administered to the president. Conley says no oxygen was administered Thursday, Saturday or Friday after Trump arrived at the hospital. But he does not rule out that oxygen was administered Friday before Trump traveled to Walter Reed.

Note how that leaves open the possibility that Trump had received oxygen on Friday before leaving for Walter Reed, and it turned out that there had been drops in his oxygen saturation on Friday and Saturday:

President Trump has “improved,” according to White House physician Sean Conley, but experienced significant oxygen drops on Friday and Saturday. His doctors said he has had no fever since Friday morning and could be discharged as early as tomorrow.

Conley declined to answer questions about the president’s lungs, including whether there is scarring or whether Trump has pneumonia.

Also on Sunday:

So the White House physician was basically leaving out critical information in order to be “upbeat” on Saturday. His desire to be “upbeat” also contradicted reports on Saturday from senior White House officials that the “President’s vitals over the last 24 hours were very concerning and the next 48 hours will be critical in terms of his care. We are still not on a clear path to a full recovery.”

This Twitter thread by Dr. Bob Wachter, chair of medicine at UCSF dissects the disconnect between Dr. Conley’s rosy assessment and things said and left unsaid:

In fairness to the President, one characteristic of COVID-19 that stood out early on in the pandemic is that some patients have “silent hypoxemia” (sometimes also called “happy hypoxia”) in which they are profoundly hypoxic but do not show the symptoms that people with such low oxygen saturations usually do. So President Trump, given his penchant for always showing “strength” and his hatred of ever showing anything he considers to be “weakness,” might well have thought his doctors were being alarmist. Be that as it may, we are getting conflicting stories regarding how sick the President really is, with some stories stating that he had experienced significant shortness of breath while his doctors paint a much rosier picture. Perhaps the worst part of the press conference Sunday was, as Dr. Wachter pointed out, the strange way they described the chest CT results. Reading between the lines, I really do get the feeling that the President is significantly sicker than he is letting on, the video that he released Saturday afternoon notwithstanding. The way Dr. Conley danced around the question of whether Trump’s oxygen saturations had ever dipped into the high 80s was also telling, given his history of evasion.

So how do we put it all together? I can only provide educated (I hope) speculation and suggest one lesson. Personally, I’m observing a conflict between the image that the President wants to project compared to the treatments he’s receiving, which suggest a significantly sicker patient than is being admitted. Of the three main treatments being given, one (dexamethasone) is definitely not appropriate for a patient with mild disease, as steroids are immunosuppressive and, if they are not needed to reduce major inflammation, run the risk of doing more harm than good, and it took until Sunday before we knew for sure that Trump had had transient hypoxia. Meanwhile, one is an experimental therapy not yet approved by the FDA (or even released under an EUA). Why did Trump get that one? I rather suspect it’s because he demanded it, and, he being the VIP-est of VIP patients, his doctors acquiesced, with the company being more than happy to provide it for the President. Two things are strongly suggested. First, Trump is likely being treated maximally, and, second, the perils and pitfalls of VIP medicine are likely strongly influencing his care, coupled with Trump’s known tendency to believe in untested treatments. Truly, practicing SBM under such conditions must be incredibly difficult, and I do not envy his doctors. The lesson? You should hold fast to SBM, but realize that it’s going to be damned near impossible with a patient like Donald Trump.

Perhaps the best summation of the question I’m asking comes from Dr. Thomas McGinn, a top physician at Northwell Health, the largest health care provider in New York State:

“The dexamethasone is the most mystifying of the drugs we’re seeing him being given at this point,” said Dr. Thomas McGinn, a top physician at Northwell Health, the largest health care provider in New York State.

The drug, he said, was normally not used unless the patient’s condition seemed to be deteriorating.

“Suddenly, they’re throwing the kitchen sink at him,” Dr. McGinn said. “It raises the question: Is he sicker than we’re hearing, or are they being overly aggressive because he is the president, in a way that could be potentially harmful?”

Of course, given the patient, there may be another explanation.

Some experts raised an additional possibility: that the president is directing his own care, and demanding intense treatment despite risks he may not fully understand. The pattern even has a name: V.I.P. syndrome.

It could, of course, be a combination of these possibilities. Again, I don’t envy President Trump’s doctors, although I do think that Dr. Conley should be slapped down for his evasiveness and lying by omission.

Coronavirus doesn’t care if you don’t believe in epidemiology and virology

It wasn’t so long ago that I wrote about so-called “super spreading events“, mainly gatherings in which COVID-19 spreads easily and widely. Another lesson that came out of this debacle soon made itself known as more and more administration officials and prominent Republicans started to test positive for COVID-19, namely that testing alone is not enough to prevent spreading. Masks and social distancing matter at least as much. This lesson was driven home by a drip-drip-drip of announcements that led to a list of at least ten people in Trump’s circle who have thus far tested positive for COVID-19 (as of Sunday afternoon), including: Donald and Melania Trump, Hope Hicks, Nicholas Luna, Senator Mike Lee of Utah, Senator Tom Tillis of North Carolina, Senator Ron Johnson of Wisconsin, his former counselor Kellyanne Conway, his campaign manager Bill Stepien, RNC Chairwoman Rona McDaniel, and former New Jersey Governor Chris Christie.

Almost immediately after Trump announced that he and his wife had contracted COVID-19, it was pointed out in many stories and op-eds how lackadaisical his administration had been towards masks and social distancing. Indeed, it’s long been known that masks, even though they work to decrease the likelihood of COVID-19 transmission, had become a political symbol, largely because President Trump detested them and mocked them as signs of “weakness” and because, apparently, he and his staff believed that testing would be enough to protect them:

The president has maintained that he doesn’t need to wear a mask because he and the people in close proximity to him are tested for the virus. But only staffers who interact with the president are tested regularly, leaving the hundreds of others who work in the White House complex vulnerable. A White House official said a random sample of staffers who work in the Eisenhower Executive Office Building next to the White House are tested daily, but the official didn’t say how many.

Indeed, at the Presidential debate last Tuesday, Trump said this about his opponent Joe Biden:

“When needed, I wear masks. I don’t wear masks like him,” the president said. “Every time you see him, he’s got a mask. He could be speaking 200 feet away from me, and he shows up with the biggest mask I’ve ever seen.”

See what I mean? The President was basically mocking masks as a sign of weakness, as performance, as a signifier of political leanings—his supporters are still accusing Biden of using masks as a “prop”—while members of Trump’s entourage pointedly took their masks off after being seated to watch the debate. (Unfortunately, he’s not wrong about masks having become a signifier of political beliefs, but he is largely responsible for that.) Indeed, he’s said even worse. It wasn’t just masks, though. The New York Times published an article Saturday detailing the hostility in the White House to masks and social distancing, describing the pressure West Wing occupants felt not to wear a mask and to act as though the virus was not a threat and how, if you didn’t want the President to be displeased with you and mock you, you didn’t wear a mask. This hostility towards masks has also manifested itself in pressure on the CDC to downplay the importance of masks and social distancing, even as it’s becoming clearer that SARS-CoV-2 is transmitted through a combination of large respiratory droplets and, to a lesser extent, smaller aerosol particles. This lack of concern for COVID-19 transmission led to an article in August in The Atlantic referring to the White House as a Petri dish, the author noting that the “most famous address in America now feels like a coronavirus breeding ground”.

All of this has led to speculation that the reception held in the Rose Garden last Saturday for Trump’s Supreme Court nominee Amy Coney Barrett was a “super spreader” event, because of how the White House flouted coronavirus guidelines recommended by public health officials:

The White House gathering on Sept. 26 to introduce Amy Coney Barrett as President Donald Trump’s nominee to serve on the Supreme Court has emerged as a likely superspreader event in the growing cluster of COVID-19 cases surrounding the president.

So far, the majority of the people who have tested positive were at the Rose Garden gathering and associated events, including individuals whose schedules would otherwise not obviously have brought them together. And the timing of their reported positive tests fits with the date of the event. It was also surrounded by other meetings with key Republicans to discuss the coming confirmation hearings

While it’s true that the event was held outside and that gatherings outside are less risky than indoor events, there were also indoor components of the reception, with not a mask to be seen, no social distancing, and even a lot of hugging. Just take a look at the photos included in this New York Times article about the reception. There are lots of shots of people indoors, with no masks, not staying anywhere near six feet from each other, and even a fair amount of hugging and getting in each other’s faces going on. In the days leading up to the Presidential debate last Tuesday, there were also a number of closed door sessions to prepare, again with no masks and no social distancing.

The lesson?

You can’t escape virology and epidemiology. Masks work to slow the spread of COVID-19, no matter how much you believe they don’t. Social distancing works. Handwashing works. Are they perfect? Of course not. They decrease, not eliminate, the risk of COVID-19 transmission. Moreover, the reason testing alone, which is what the White House was relying on, is insufficient is because there is a significant false negative rate for COVID-19 tests, as there is time between the virus infecting you and its being detectable by nasal swab when you can still be infectious and it is known that people are most infectious a couple of days before they develop symptoms and people can be contagious days before testing positive for the virus. Testing is important, so that asymptomatic and presymptomatic COVID-19 carriers can self-isolate, but without other public health interventions, including social distancing and masks, testing alone will not keep a group safe, as described here:

The administration relied on Abbott Laboratories’ ID Now rapid test at the Sept. 26 event for Judge Barrett. After guests tested negative, they were ushered to the Rose Garden, where few people were wearing masks. The White House didn’t comment on whether anyone screened at the event tested positive.

Public-health experts say the White House isn’t using the test appropriately, and that such tests aren’t meant to be used as one-time screeners. Regardless of the type or brand of test, any strategy that relies solely on testing is insufficient for protecting the public against the virus, epidemiologists and researchers say.

The problem is that the White House seems to view COVID-19 testing is akin to a metal detector and that a one-time test means that a person is safe when infected people can transmit COVID-19 before they test positive for the virus:

All tests, including those processed in a lab, can produce false negatives, he and other experts say. Some studies have shown that the Abbott Now ID test, which can produce a result in minutes, has around a 91% sensitivity—meaning 9% of tests can produce false negatives.

“A metal detector that misses 10% of weapons—you’d never, ever say that’s our only layer of protection for the president,” said Dr. Jha.

Abbott itself points out that no test detects the virus immediately after the person becomes infected.

In the end, what is surprising is not that President Trump and a growing number of his associates got COVID-19 last week. What’s surprising is how lucky the White House has been that something like this hasn’t happened until now. You can’t fool Mother Nature, as they say, and Trump didn’t even try to protect his people, not even letting several of his key allies know after he tested positive that they had been exposed. Worse, he arrived to the debate on Tuesday too late to be tested for COVID-19 and was allowed in on the “honor system”. Given the timing, it was not unreasonable to wonder if Trump could have infected Joe Biden, although fortunately, so far, it appears that this did not happen.

Basically, SARS-CoV-2 doesn’t care if you believe in science or not.

Returning home to science-based medicine

It is rather amusing to recall how much Trump has promoted dubious and unproven treatments for COVID-19 starting back in March. Just search this blog for “hydroxychloroquine” for a sampling. I don’t want to go into detail regarding the story of this drug, as I’ve discussed it many times already, but for those who don’t want to click on the links I’ll helpfully provide, this is the Cliffs Notes version.

Back in January, as the pandemic first hit Wuhan, China, some Chinese doctors thought they had made an observation that the novel coronavirus did not infect 80 patients with systemic lupus erythematosus (SLE) who were taking quinine-based drugs like hydroxychloroquinine (HCQ) and chloroquinine (CQ). As a result of that and old evidence of antiviral activity for the drugs, they became interested in using these antimalarial drugs to treat COVID-19. (Never mind that immunosuppressed patients are exactly the patients most likely to assiduously follow the recommendations of public health authorities during a pandemic.) A number of clinical trials were registered, and, based on anecdotal reports and small clinical trials (nearly all of which are as yet unpublished), in February the Chinese government published an expert consensus recommending CQ or HCQ for patients with COVID-19. Other nations, thinking the Chinese must know what they’re talking about, took the recommendation at face value, and it wasn’t long before HCQ (±azithromycin, ±zinc, etc.) became a de facto standard of care for COVID-19. A “brave maverick doctor” in France named Didier Raoult published some breathtakingly bad studies supporting the use of the drug, and eventually President Trump got on the bandwagon, leading to an emergency use authorization (EUA) by the FDA for HCQ in late March. Meanwhile, a number of quacks, complete with “miracle cure” testimonials, were hyping HCQ, including the aforementioned Dr. Raoult, Dr. Vladimir Zelenko (who claimed to have treated hundreds of patients successfully), Dr. Stephen Smith (ditto), and even America’s quack, Dr. Mehmet Oz himself. Also, President Trump himself said in May that he was taking HCQ to prevent COVID-19, although he apparently stopped before too long.

Over the next few months, there was a drip-drip-drip of negative studies, ultimately including negative randomized controlled clinical trials, of hydroxychloroquine for COVID-19, and ultimately the FDA rescinded the EUA and hydroxychloroquine fell out of favor, although that hasn’t stopped even quackier doctors, such as Dr. Stella Immanuel, a Houston physician who believes that sex with demons causes illness and has claimed to have cured hundreds of COVID-19 patients with HCQ. Amusingly, she is very unhappy that President Trump has not, as far as anyone can tell from news reports, actually used HCQ to treat his COVID-19, Tweeting:

And, publicity hound that she is, Dr. Immanuel even offered to prescribe it herself:

I was quite amused by this for a number of reasons, but the most important one of all is what I started out saying, namely that it’s all fun and games (and/or grift) to promote unproven “cures” for a deadly disease, but when the quack’s life is on the line it’s funny how fast he comes back to science-based medicine. Sure, President Trump is reportedly getting some unproven therapies, such as vitamin D and zinc, but chances are that vitamin D and zinc probably don’t do any harm. It’s also true that he availed himself of an experimental treatment, but that experimental treatment at least has some promising preliminary data and is scientifically plausible as a potentially effective treatment for COVID-19. However, otherwise, Trump seems to be accepting more or less science-based treatment for his COVID-19, albeit likely with its level of aggressiveness amped up because of his VIP status. Basically, he’s (mostly) ignored the quacks and listened to doctors at Walter Reed Medical Center.

So we’ve learned at least three lessons here, I hope. First, VIPs do not necessarily get the best care, particularly when the VIP is Donald Trump and particularly when evidence-based protocols for COVID-19 are still in flux, but particularly when the VIP’s political need to paint the rosiest picture possible of his condition conflicts with the need for transparency. (He even staged a photo op showing him “working” in which he appeared to be signing a blank piece of paper.) Second, the virus doesn’t care if you believe in science or not. Finally, for many a quack and grifter, it’s all fun and grift to promote pseudoscience until you yourself are facing a potentially life threatening condition. I’m sure there will be more lessons as this story unfolds.

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Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.