Yesterday President Donald Trump revealed this interesting re-election strategy:
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This is a Hail Mary strike taken at high personal risk.
Trump was certainly not well enough to get released from the hospital.
It is not really known when Trump got infected with the SARS-CoV-2 virus and when he fell ill with Covid-19. The treatments his doctors said they used with him are somewhat conflicting. After Trump was diagnosed with Covid-19 he was given a high dose of monoclonal antibodies which directly attack the virus and lessen the overall growth of viruses. The antiviral drug remdesivir which lowers virus RNA production was also given:
[I]t would seem that if you’re going to give monoclonal antibodies, that they would be best given early in the course of the disease, when therapy is still in antiviral mode. The addition of a five-day course of remdesivir to the treatment regimen fits that as well: both of these are designed to lower the amount of virus present and (in theory) keep the disease from progressing to a more severe stage.
Both therapies make most sense in the first phase of a virus infection when it is still only in the upper part of the respiratory system. In that phase the normal immune system is still building up its defenses. But Trump seems to have already been in the second phase of the infection where the virus is in the lungs and when the immune system starts to attack the body. He at least twice had too little oxygen in his blood likely without feeling it. This "happy hypoxemia" is typical for Covid-19:
The adequacy of gas exchange is primarily determined by the balance between pulmonary ventilation and capillary blood flow, referred as ventilation/perfusion (V/Q) matching. In the initial phase of COVID-19, several mechanisms contribute to the development of arterial hypoxemia, without a concomitant increase in work of breathing. Rapid clinical deterioration may occur.
At that stage Trump was brought to the Walter Reed hospital and began the antiviral therapy. But his illness must have worsened. After his second day in the hospital his doctors announced that he had been given the corticosteroid dexamethasone:
[The] severe stage shows up as an overactive immune response leading to the well-known “cytokine storm”, and potentially big trouble. It really looks like the best therapy we have for that at the moment is dexamethasone. So I found it interesting – and not in a good way – that the president’s medical team had actually put him on dexamethasone, because its mode of action is to damp down the inflammation response. And if a person is still in the early stages of infection, that’s the opposite of what you want to do.
The doctors also said that Trump's chest CT showed what they 'expected' without describing what that was. It likely means that the virus had started to attack the lungs:
Due to increased lung edema (leading to ground-glass opacities and consolidation on chest imaging), loss of surfactant and superimposed pressure, alveolar collapse ensues and a substantial fraction of the cardiac output is perfusing non-aerated lung tissue, resulting in intrapulmonary shunting.
That increased the need to give additional oxygen and to start with the anti-inflammatory steroid.
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If the disease can not be stopped at that point, the next dangerous consequences, small blood clots (microthrombi) are likely to occur. Trump will have to take some kind of blood thinner to prevent those from causing a stroke.
No sane doctor would at that point release a patient from the hospital.
But Trump wanted to be back in the White House. He calculated that he needs to show that the virus can be beaten.
He has no other chance to win the election. The people rightly believe that he screwed up the U.S. response to the pandemic. Even older voters who voted for Trump in 2016 are now saying that will vote against him:
In a recent Washington Post-ABC poll, 52 percent of likely voters over 65 supported Biden, compared with 47 percent for President Trump. Four years ago, Trump won those voters over Hillary Clinton.
Trump was warned of this early on. As Tomas Pueyo wrote back in April:
The older you are, the more likely you are to both vote Republican and die from the coronavirus. Voters aged 80+ are 80 times more likely to die from the coronavirus than those under 40 (16% fatality rate vs. ~0.2%).
This effect is strong enough that people who voted for Trump in the 2016 election are around 30% more likely to die from the coronavirus than Democrats. In some swing states from the 2016 election, such as Pennsylvania, if the coronavirus were to run wild, this effect alone could have wiped out up to 30% of the gap between Republicans and Democrats in the 2016 election.
Trump can no longer convince the voters, especially the older ones, that he did everything to protect them from the virus. What he probably still can do is to convince them that it does not matter because the virus can be beaten.
To do that Trump had to make himself the showcase.
I do not want to suggest that Trump intentionally infected himself. But he did pretty much everything one should not do if one wants to prevent that.
Trump is relatively old, he has additional risk factors and despite that he now can say that he has beaten the virus. Should nothing further happen to him there is no way that anyone can doubt that.
His real message in this White House video is: "I have beaten it. You can beat it. The virus does not really matter. Just carry on."
That message, in various variants, will now get repeated every day. Some people will start to believe it and it may indeed help Trump to win the upcoming election.
There are risks in that strategy. Some of those who recently got infected in the White House may die. That would lead to accusations that Trump has caused that by being careless.
Another risk, and a personal one that Trump is taking, is the fact that he has not yet beaten the virus. He may still need oxygen. His lungs are still impacted and will take many weeks to heal. This virus is insidious. There is a risk that there will be some kind of relapse or complication that will need additional treatment in Walter Reed. The White House is equipped for medical emergencies but not for the intensive care that often follows. Should Trump need to go back into the hospital his strategy will likely fail.
Trump will still get dexamethasone. That drug has side effects and withdrawal from it can be tricky:
- The production of corticosteroids is controlled by a "feedback mechanism," involving the adrenal glands, the pituitary gland, and brain, known as the "hypothalamic-pituitary-adrenal axis" (HPAA).
- Using large doses for a few days, or smaller doses for more than two weeks, leads to a prolonged decrease in HPAA function.
- Steroid use cannot be stopped abruptly; tapering the drug gives the adrenal glands time to return to their normal patterns of secretion.
- Withdrawal symptoms and signs (weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea, abdominal pain) can mimic many other medical problems. Some may be life-threatening.
It is unlikely that Trump will soon go back on the campaign trail. He can be happy if he has enough energy for the next TV debate with Joe Biden. He will probably need additional drugs to sustain it.
When the British prime minister Boris Johnson fell ill with Covid-19 his approval in the polls increased. We have not seen that effect for Trump. But the polls may be wrong. They were wrong in 2016 because many who were asked did not want to admit that they would vote for Trump. That effect may now be even stronger than it was back then.
Trump's return to the White House is sending message of confidence. It is likely that it will bring him additional votes.
By deciding to leave the hospital early Trump showed his willingness to take a significant personal risk to achieve his reelection. One may hate the bastard and still admire him for that.