SUBSCRIBE NOW
OPINION

Trump's COVID prognosis: 3 scenarios based on sparse facts from an opaque White House

The president's health matters. But we can only speculate because his doctor has hidden behind confidentiality laws to withhold negative information.

Dr. Ezekiel J. Emanuel and Dr. Vin Gupta
Opinion contributors

At a minimum, there will be 3.5 months between when President Donald Trump first contracted coronavirus and when a president will be inaugurated on Jan. 20, 2021.  While this seems a brief time, the world is a dangerous place. President Trump’s health matters.   

What can the American public anticipate regarding his expected clinical course over this time period? The answer to this question is absolutely vital, since many survivors of severe COVID-19 pneumonia (which the president had) have experienced setbacks, hospital readmissions and prolonged intensive care stays requiring months of rehabilitation.

What we do know of the president’s current condition is informed by what has been shared voluntarily and bolstered by what’s been willfully withheld from public view. Concerningly, Trump was reportedly hypoxemic (low oxygen saturations, less than 94%) for a period of time, had shortness of breath, and required supplemental oxygen. Those are all clear signals that the president might have experienced the most feared and harmful injury from COVID-19: pneumonia. To be clear, nearly all of the 213,000 Americans who have lost their lives to this virus died for this reason alone, often on ventilators (though strokes and kidney failure may be contributors to poor prognoses in the patients).

Bush's colon, Obama's prostate 

We can only speculate because the president’s physician has selectively released medical data, hiding behind confidentiality laws to withhold any negative information. Knowing the results of a CT-scan would be enormously useful in understanding the president’s severity of illness, as high quality studies have revealed that such data could provide very reliable and early evidence of infection. An arterial blood gas test conducted when he arrived at Walter Reed medical center might have also revealed the extent of the president’s pneumonia, helping forecast an anticipated timeline to full recovery.  (As a useful barometer of prior presidential health disclosures, you can readily read up on the details of former President George W. Bush’s colonoscopy or President Barack Obama’s prostate exam.)

President Donald Trump on the Truman Balcony at the White House in Washington, D.C., on Oct. 05, 2020.

The latest revelation about the president's "detectable" COVID antibody levels Wednesday suggests he has had the disease longer than admitted, because his antibodies were merely "detectable" a few days after he had been injected with a powerful antibody cocktail. From preliminary non-peer reviewed data, the Regeneron cocktail appears to be effective in halting progression of COVID-19 illness in patients who do not have strong antibody responses to COVID. Giving it seems reasonable, although not enrolling him in a clinical trial seems both unethical and a mistake.

Initiating Remdesivir and Dexamethasone quickly is consistent with our own National Institutes of Health guidelines for the treatment of severe COVID-19 pneumonia. The president rules in for that definition because of his reported low oxygen saturations and supplemental oxygen requirement. That he was reportedly short of breath before his transfer to Walter Reed and visibly so on live television on his return to the White House only further clinches this diagnosis.

Three most plausible COVID courses

What can we reasonably expect regarding the president’s most likely clinical course? We have to speculate but there are the three most plausible scenarios.

Scenario One: Trump rapidly recovers from his pneumonia with no residual effects in approximately two weeks’ time from the onset of his symptoms (Oct. 1). This is the best case outcome for him, his inner circle and the country’s national security. The shortage of information makes the likelihood of this scenario ultimately unknown, although Trump planned to resume public events as early as Saturday. He is unique in receiving the Regeneron cocktail almost immediately after diagnosis in combination with Dexamethasone and Remdesivir. 

COVID reset: From Trump on down, people of means have shaped our COVID-19 experience. That must change.

Scenario Two: Trump is readmitted to Walter Reed for recurrent shortness of breath and low oxygen levels, an outcome that would amount to a guilty verdict that the president’s physicians were uniquely cavalier in permitting discharge when virtually every other expert argued otherwise. 

What’s clear about COVID-19 is that its course is unpredictable across demographics and even within the same age or ethnic category. Yet, there’s consensus that those older than 65 years of age, particularly those like the president who are technically obese, are hospitalized and ultimately die at far higher rates than the rest of the population. Of these victims, many have variable courses. Some initially improve, as in the case of the president, only to decline again 7-10 days after symptom onset, often with severe manifestations requiring ICU-level care.

COVID long-haulers: I caught coronavirus in March. I still haven't fully recovered.

Stopping short of speculating on probabilities for this scenario, the data is clear: More than 90% of individuals who end up hospitalized with COVID-19 have at least one cardiovascular risk factor like obesity and are primarily elderly (65 or older).The president meets both criteria. Therefore, a friendly pre-recorded TV interview aside, vigilance is demanded, particularly as the president continues to be symptomatic as evidenced by his coughing on the phone Thursday night with Fox’s Sean Hannity.

Scenario Three: Trump recovers from the acute episode but goes on to develop chronic symptoms.  This is the vaguest of possibilities but physicians are seeing a growing number of “long-haulers” — individuals who’ve survived severe COVID-19 pneumonia after a hospitalization, but months after their initial recovery, they have not regained full functionality and their normal activity level. In addition to fatigue and shortness of breath, many experience some mental fog or slowness. Only time will tell if this outcome is the president’s fate, but as we learn more about COVID-19’s impacts on the human body, it is one to keep closely in mind.

Ultimately, the American people will remain limited on their understanding of how coronavirus will impact this president. Unless there's a dramatic readmission to Walter Reed, we’ll likely be left to guess about how the president’s health has been impacted, if at all. And that’s a shame, since he could use his own experience to educate the American public on the dangers of this virus and provide anticipatory guidance — in addition to empathy — to those who’ve fallen ill.

Dr. Ezekiel J. Emanuel (@ZekeEmanuel) is vice provost for global initiatives, the Diane S. Levy and Robert M. Levy University Professor and chair of the department of Medical Ethics and Health Policy at the University of Pennsylvania, and a senior fellow at the Center for American Progress. Dr. Vin Gupta (@VinGuptaMD) is a pulmonologist and Assistant Professor of Health Metrics Sciences at the University of Washington School of Medicine.