A Tale of Two Covids: President Biden’s illness means something very different than Trump’s did.
Two consecutive Presidents have had Covid-19. It’s okay to notice that the average case in 2022 is better than it was in 2020, but that we still have a ways to go.
Let’s be honest. On average, getting Covid-19 is not as scary as it once was. Vaccines, prior infections, and therapeutics have rendered the average case a lot less dire, in terms of the most feared outcomes. The news that President Biden has tested positive for Covid-19 means something different than it meant when President Trump did so back in October of 2020.
I remember when I first heard the words: “President Trump has Covid.” It was October 2nd, 2020. We had steroids, which improved mortality rates in patients with low oxygen levels. We had Remdesivir, which shortened hospitalizations, but was far from the game-changer some had claimed. We had monoclonal antibodies, which probably made some difference but not nearly as much as hyped. We did not yet have vaccines.
The next day, Trump was taken to the Walter Reed hospital. Rumors were flying that he was not doing well. I remember taking a call from the New York Times’s Apoorva Mandavilli while I was at the park with my family.
“This is a nightmare,” I told her.
Even with my well-documented disdain for Donald Trump, I meant it. All of the possible outcomes were bad. On one hand, Trump’s condition could deteriorate. As much as I hated his politics, I am still a physician and I hope for favorable outcomes in all cases. Potentially losing a President to Covid-19 would be devastating for the nation, regardless of anyone's political affiliation. On the other hand, if Trump’s illness turned out to be mild, I worried that this would re-enforce the notion that the virus was nothing to worry about. That of course wasn’t true, but the law of large numbers often obscured that—and it still does. (If all US residents were to be infected and 1% were to die while 99% were to live, that would still add up to 3.3 million deaths.) If Trump’s illness ended up being a walk-in-the-park for him, I worried that people might later be less interested in effective vaccines.
In the week that followed, the White House initially obscured and then revealed concerning details of Trump’s course. At some point, we later learned, his oxygen levels dropped markedly. He very well could have ended up in a coma, on a ventilator, or worse. As we all know, Trump pulled through. But make no mistake, President Trump had Covid-19 pneumonia. I want you to notice that word pneumonia.
When I learned today that President Biden has contracted Covid-19, my reaction was different. My immediate level of concern for Biden's health was markedly lower than was my concern for Trump's back in 2020. That’s because Biden has received 4 doses of a Covid-19 vaccine and he’s already started taking Paxlovid, an antiviral drug that has been shown to decrease the odds of progressing to severe illness. Biden’s vaccination status, the availability of Paxlovid, and his health profile (Biden does not have obesity, a major risk factor for poor Covid-19 outcomes, which Trump does), sum up to eons more protection than Trump had at the same point in his illness.
Nevertheless, upon hearing the news that Biden tested positive for Covid-19, I still had some concerns. The good news is that President Biden is highly unlikely to develop Covid-19 pneumonia, the driving force behind so many deaths among the unvaccinated. Biden’s protection from that horrific pneumonia which frontline providers quickly learned to hate in early 2020 results from a combination of the vaccines, Paxlovid, his relatively better underlying health, and possibly the SARS-CoV-2 variant which he has contracted.
Overall, Biden’s risk of being hospitalized is low, and much lower than Trump’s for the above reasons. But at age 79 and with atrial fibrillation (a heart rhythm whose implications can range from mild to serious), his risk of a “breakthrough hospitalization” is not trivial.
I want to take you under the hood on “breakthrough hospitalizations”—that is, hospitalizations in people who have been vaccinated against Covid-19—for a moment. We’ll use data from Massachusetts this year as the example. This year, around 73% of Covid-associated hospitalizations here have occurred in unvaccinated individuals. That’s impressive given that over 95% of seniors in the state (by far the highest-risk group) are vaccinated. Think about that. Even though a very small minority of the highest-risk group in Massachusetts is unvaccinated, that group still comprises a large majority of our Covid-related hospitalizations. As I wrote last year, that’s actually hard to accomplish, because the higher the vaccination rate is in a region, the fewer unvaccinated targets there are. All of this implies that the vaccines are actually performing even better than we might have been led to think. An “own-goal” on the part of the pro-vaccine movement is that many among the public have come to think that our vaccines are failing because infections are happening in vaccinated individuals. But remember, the vaccines are highly effective at preventing infections for a relatively short period of time. But the vaccines succeed in preventing severe illnesses for far longer. That’s what the vaccines were designed to do and that’s what they accomplish.
An interesting wrinkle, however, is that only around 30% of Covid-19-associated hospitalizations statewide this year have been thought to have been primarily “for” Covid-19. In other words, in 2022, most people in Massachusetts being hospitalized while having Covid-19 are primarily being hospitalized for other reasons, rather than Covid-19 pneumonia or low oxygen levels like we used to typically see in the pre-vaccine days. However, as I’ve written, this does not mean that Covid-19 is merely incidental. Quite the contrary, I believe. What’s happening are a lot of “Covid tip overs” (or “Covid plus") in the unvaccinated who have been infected before, and, in some cases, among the vaccinated. For some people with underlying health conditions, Covid-19 likely represents a 2nd punch (to paraphrase my colleague Dr. Harlan Krumholz) that they can’t absorb and shake off. While young and healthy people can take that Covid-19 hit without needing hospitalization, older people and others with significant medical problems can’t so easily, meaning that they require hospitalization.
What does this mean for President Biden? It means that if his condition worsens (though he’s doing well so far) and he is hospitalized in the coming days, it’s unlikely that it will be for Covid-19 pneumonia. That’s a good thing because it means his life is in far less danger. But he could end up at Walter Reed because his atrial fibrillation acts up, or due to dehydration. In other words, if Biden is hospitalized, it’ll be far less serious than it would have been had he developed pneumonia (as President Trump did, and as so many now-dead Americans did in the pre-vaccine, pre-Paxlovid era), but it will still be because of Covid-19.
All of this underscores the importance of keeping older people up-to-date on vaccines, especially as increasingly immune-evasive variants have cropped up. These days, many healthy vaccinated people can get Covid-19 and expect not to be hospitalized. But there’s a large group, primarily comprised of seniors and the immune-compromised, for whom getting Covid-19 amounts to playing roulette with an existing health problem. So, keeping infections down in people over the age of 50 (where these risks are highest) is an extremely important goal, in terms of minimizing immediate severe burdens on patients and keeping the healthcare system from being strained. (Keeping infections down in younger people has other benefits, including decreasing spread to at-risk communities and limiting Medium and Long Covid.)
Recently, a couple of colleagues I respect were quoted as saying that given the emergence of the BA.5 subvariant of Omicron, that we are “basically back to square one,” in terms of the Covid-19 pandemic. To me, that implied that what they had been seeing on the ground was reminiscent of early 2020, prior to the vaccine era: Covid-19 pneumonia left-and-right; intubating tons of patients; more deaths than we’d ever seen in such a short period.
I emphatically disagreed with those takes—at least based on what we’ve been seeing here in Massachusetts. So, I reached out to them and we had productive conversations. Long story short, neither of them really thinks we are back to square one. They not seeing those Covid-19 pneumonias in droves, like we used to in 2020. But both are worried with what they are seeing on the ground—lots and lots of infections.
While I’m generally against tone policing (and some of my medical colleagues throw abject temper tantrums when other experts overstate Covid risks), I think it does matter that we not say things like “this is 2020 all over again,” unless that’s truly the situation. It isn’t, as of now. If we do ever face a variant that once again makes that repugnant Covid-19 pneumonia a common occurrence among both unvaccinated and vaccinated people, that will indeed be akin to being back to square one. If that happens, I’ll let you know.
For now, I wish the President a speedy recovery. Hopefully, his case will be a demonstration of how far we have come. And yet, the fact that he has the virus at all reminds us how far we still have to go.
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Thanks to Benjy Renton for data acquisition.