Courtesy of Charles Deluvio

After President Trump disclosed that he and the first lady of the United States tested positive for the coronavirus on Friday, Oct. 2, physicians, scientists and public health experts took to social media and TV networks to discuss the information made publicly available about his clinical state.

The coronavirus is known for its ability to cause debilitating symptoms, long-term ramifications and even death. When the President became ill, it therefore brought into question the meaning of his diagnosis for the future of his campaign and presidency. It remains unknown exactly where and how Trump and his wife contracted the virus. But the Trumps’ diagnosis and the Sept. 26 Rose Garden ceremony that announced Amy Coney Barrett as Supreme court nominee were only six days apart, which stirred alarm among experts.

Anthony Fauci, director of the National Institute of Allergies and Infectious Diseases and member of the White House Coronavirus Task Force, dubbed the ceremony a “superspreader event.” Within a matter of days, at least eight of the event’s attendees tested positive for the virus. According to the Federal Emergency Management Agency and the Washington Post, a total of at least 34 members of the White House staff and contacts to the President have also tested positive.

Esther Choo ’94 MED ’01, professor of Emergency Medicine at the Oregon Health & Science University, told the News that she was concerned about the lack of contact tracing done by the White House after Trump’s diagnosis. She said that she was expecting the White House to implement an efficient contact tracing program.

“It would be difficult, but not impossible,” Choo said. “You [have to] mobilize the CDC, hire professional contact tracers who can work very effectively to get people’s calendars and figure out who was working and when.”

Similarly, Yale Medical School professor Howard Forman said that the White House had an “obligation” to implement rigorous contact tracing around the President and any affected individuals in the White House.

Forman wrote in an email to the News that contract tracing would have helped to identify more infected individuals, protect their loved ones and, possibly, ensure access to earlier treatment for those suffering from the virus. Even after the President’s return to the White House, Forman wrote that it is not clear that the Trump administration will implement these effective contact tracing strategies.

“I think this is going to be almost like a superspreader week, or superspreader era, and I don’t know that we’ll ever know the extent because they are not aggressively tracking people down, testing and putting people in quarantine,” Choo said.

The President’s Treatment

On the day that he announced his diagnosis, the President was airlifted into Walter Reed National Military Medical Center, spawning confusion about his prognosis following a series of inconsistent White House statements. On the same day, White House chief of staff Mark Meadows said that the President had “mild symptoms” while the physician to the President, Sean Conley, released a memo detailing that Trump was administered eight grams of Regeneron –– a high dose of an experimental antibody cocktail that has yet to be FDA-approved. These statements, which implied conflicting information on Trump’s infection, seeded public alarm and raised questions surrounding the gravity of the President’s illness.

According to Conley, Trump received a steroid treatment of dexamethasone after arriving at the hospital and began a five-day course of treatment of Remdesivir, an antiviral medication authorized by the FDA only for emergency use on hospitalized patients with the coronavirus. After a three-day stay at the hospital, Trump was discharged and returned to the White House.

“The average patient who is still receiving intravenous medication and within that moderate to severe category would not leave the hospital,” Choo told the News. “The fact that Trump can speaks to the world class facilities that are available in the White House.”

Some experts have suggested that COVID-19 could provoke psychiatric effects. According to Choo, these psychiatric effects could include anxiety, psychosis and depression, meaning that it is possible that Trump experienced some neurological complications. She also mentioned the President’s reported fluctuating oxygen levels could have had an impact on his brain’s oxygen supply, affecting his mental status and judgement.

One other cause of psychological complications could be the drug cocktail administered to the President, especially the dexamethasone steroid marketed as Decadron.

“There’s a lot of unknown impact of this monoclonal antibody cocktail, the Remdesivir, the steroids, and we don’t know how they interact along with his baseline medication,” Choo said. “Certainly steroids can do it alone, but the more you add all these other reasons for why he might not have a stable mental state, there’s a high likelihood that he is not himself behaviorally.”

Professor of Immunology Akiko Iwasaki — who was named to a list of “50 experts to trust in a pandemic” — explained that it is too early to tell if the virus will have long-term effects on the President’s health. She also stated concerns for Trump’ s mental capacities, since “Dexamethasone [or Decadron] can affect a person’s ability to think clearly.”

Forman emphasized a similar point in an email to the News. “If the President were any other patient, we would be cautious about interpreting his behavior during this time when he is obviously going through a very serious illness and on a drug that is known to alter patients mood and behavior… Almost nobody else would attempt to be on the job when under such treatment.”

Iwasaki explained the still-doubtful monoclonal antibody cocktail administered to the President. According to her, the treatment was tested in the early stages of infection in a few individuals.

“[It] was reported to bring down viral load, especially in people who did not develop their own antibodies,” Iwasaki wrote in an email to the News. “It is unclear whether it impacted the course of President Trump’s illness.”

The President’s Behavior

On Sunday evening, to the surprise of physicians all over the country, Trump left Walter Reed in an SUV operated by Secret Service members to wave to his supporters before returning to the hospital.

When asked about the President’s decision to leave the hospital for a car ride, Choo said she believes that he was still infectious. According to her, the car ride sent a clear message about the virus to the public.

“[He was] wearing a regular mask rather than a N95 mask, having people in close contact with him, …. that whole thing and his messaging about ‘this is not a big deal’, ” Choo said. “That all sends a signal to people about being casual about your likelihood of infecting other people.”

At a press conference held on Monday morning, Conley cautioned that the President “may not be entirely out of the woods yet.” However, Conley maintained that the President’s COVID-19 condition was stable.

Before returning to the White House, Trump tweeted: “Feeling really good! Don’t be afraid of Covid. Don’t let it dominate your life.”

On Monday evening, Trump disembarked Marine One, climbed the staircase of the South Portico, removed his mask and saluted the helicopter before entering the White House.

In an email to the News, Iwasaki wrote that she believes President Trump was probably still infectious when he left the hospital. According to Iwasaki, the only way to prevent further spread would be to quarantine all of his personal staff and test them.

She also demonstrated concern for the President’s staff, who had “no choice” with regards to their contact with him. She added that his behavior put all of the people around him at risk for infection.

The President’s mental health

In an interview with the News, Bandy Lee –– assistant clinical professor of psychiatry and editor of the essay collection “The Dangerous Case of Donald Trump” –– said that since his diagnosis, the President seemed disinhibited and irrational.

When speaking of possible psychiatric manifestations that could linger even after the President eliminated the virus from his body, Lee also explained that symptoms of this kind can be difficult to identify without the relevant expertise, since abnormal psychological signs are often a variation of behaviors that are deemed normal.

“What is psychiatrically salient is not always apparent to the lay public,” Lee said. “The public is more likely to interpret pathological signs as a variation of what they have seen, … the human normal range is very vast, with a lot of variation, and so it is very hard to tell apart what is pathological, unless you have experience of what it looks like.”

Because of that, Lee told the News that access to the voice of experts in public discourse is essential. She believes that it is the responsibility of mental health professionals to alert others about the dangerously subtle nuances that discern psychiatric manifestations from regular behavior.

In the President’s case, Lee says that this is especially alarming because she believes that “he is not only a danger to himself but also a danger to others.”

Lee also emphasized that the President should have received a mental health evaluation upon discharge from the hospital.

“We know that he is very invested in a certain narrative, which is that the virus is no big deal and that we can ignore it,” Lee said. “Reality is also very inconvenient for him, to the point of being intolerable, so he will go to great lengths to deny reality and to advance his wishful fantasy thinking.”

According to Lee, dangerousness and unfitness evaluations of the President are especially important in light of the fact that lives depend on his ability to perform his job.

Nevertheless, Lee told the News that no such mental evaluation is currently required of someone who is taking office.

“Every law enforcement officer, every military officer and certainly those who handle nuclear weapons are supposed to go through rigorous mental fitness testing,” Lee said. “So a glaring omission is that a president is not required to pass even a basic mental fitness test before taking office.”

In response to the President’s tweet, assistant professor of epidemiology and 2018 MacArthur Fellow Gregg Gonsalves — who was also named one of “50 experts to trust in a pandemic” — described Trump’s comments as “irresponsible in the extreme” in an email to the News. Gonsalves stated that COVID-19 is a serious and potentially deadly virus whose danger should not be underestimated. 

Forman highlighted that the President has access to the best resources and treatments in the country that are unavailable to even the richest Americans — information that was omitted from Trump’s 50-word tweet.

“The President has a unique and powerful standing in the world: he can assuage fear by supporting the public health measures that are embraced by scientists inside and out of his administration,” Forman wrote in an email to the News. “I would love for him to use his platform to mitigate the harm that this pandemic continues to cause.”

The Future of Trump’s Electoral Campaign

Choo expressed concern for the President’s physical state over the next month.

“There are many ways that the president could potentially not be perfectly well by [the election], and … I think he will experience some lingering symptomatology that goes into November,” Choo said. 

With regards to the President’s mental fitness, Lee told the News that she and other psychiatric experts across the country performed a basic mental capacity evaluation of the President in April 2019 using the testimonies collected in the Mueller report. 

According to her, even before the President had COVID-19, he failed to meet every single criterion in the test. Lee said that the fact that the disease could interfere with his mental faculties further, superimposing upon what had been previously observed, is concerning and could mean that he is “likely to be unfit for any job,” especially that of president.

Gonsalves similarly cited the President’s handling of the epidemic as one of the biggest failures of the administration. 

Gonsalves wrote that the Trump administration’s handling of the COVID-19 pandemic has “been a wreck, a deliberate scuttling of our national pandemic response from the start. [The President] will go down in infamy for this among his many crimes.”

As of Oct. 11, the Centers for Disease Control and Prevention reported 7,694,865 total COVID-19 cases in the United States.

Sydney Gray | sydney.gray@yale.edu

Beatriz Horta | beatriz.horta@yale.edu

Maria Fernanda Pacheco | maria.pacheco@yale.edu