"Don't Fight the Fed" is an old saying that advises business investors to align their choices with the actions of the Federal Reserve System, the U.S. central banking system which has several potent tools at its disposal to influence stock prices. When it comes to understanding and preventing the spread of infectious diseases, an analogous maxim might be, "don't fight science," or, more specifically, epidemiology.
A pertinent example is the outbreak of COVID-19 among President Trump, First Lady Melania Trump, senior presidential advisor Hope Hicks, White House press secretary Kayleigh McEnany, and an escalating number of assorted White House and congressional aides, staffers, and politicians who have attended recent presidential events. At a succession of meetings, political rallies, and events with foreign dignitaries, attendees violated almost every rule of prevention which, in concert, reduce (but cannot eliminate) the probability of infection.
Perhaps the epitome of reckless behavior was the September 26th White House Rose Garden ceremony celebrating the nomination of Judge Amy Coney Barrett to the U.S. Supreme Court, where there was hardly a mask visible in the crowd of more than 150 invited guests, who were seated elbow-to-elbow, as an image captured by Getty Images exposed.
Nor was there much distancing in evidence during the reception that followed. In another image, captured by AP's Alex Brandon, we saw Notre Dame President the Rev. John Jenkins standing in the background, as former New Jersey Gov. Chris Christie engages with guests in the White House Rose Garden—his arm wrapped around one of the attendees. Both men have tested positive for the coronavirus.
The Washington Post described the (lack of) precautions thusly:
Attendees were so confident that the contagion would not invade their seemingly safe space at the White House that, according to [Notre Dame University President, the Rev. John] Jenkins, after guests tested negative that day they were instructed they no longer needed to cover their faces. The no-mask mantra applied indoors as well. Cabinet members, senators, Barrett family members and others mixed unencumbered at tightly packed, indoor receptions in the White House's Diplomatic Room and Cabinet Room.
Five days later, that aura of invincibility evaporated. On October 1st, counselor to the President Hope Hicks, who had reported feeling symptoms of COVID-19 during a trip with the President to Minnesota on Wednesday, tested positive for the virus. Then, more dominoes began to fall.
The Barrett nomination event is not an isolated case. In another image, captured by AFP's Andrew Caballero-Reynolds, we saw senior White House staff, including Jared Kushner (center), Stephen Miller (second from right), and Hope Hicks, walking to the President's helicopter, Marine One on September 23rd. No one is wearing a mask, and it is well known that the absence of masks is de rigeur on Air Force One.
In the medical and epidemiology communities, the only surprise is that an outbreak at the White House didn't occur sooner. You can't fight science.
WE IGNORE SCIENCE AT OUR PERIL
The SARS-CoV-2 virus (which causes COVID-19) is highly contagious. The pillars of prevention are: masks; social distancing; avoidance of crowds, especially in indoor, poorly ventilated spaces; and frequent hand washing. I can't speak to the hand-washing, but the other measures have been flagrantly, repeatedly, and publicly ignored—apparently because they're regarded, especially by men, as a sign of weakness, insufficient machismo, or just too darned inconvenient.
The regimen that was followed by the White House to avoid COVID-19 infections inside the "bubble" relied too heavily on testing. There are several reasons that that is insufficient. First, there is a lag between a person being exposed to the virus and the appearance of enough RNA (the virus's genetic material) for the test to detect. Second, the tests don't have 100% sensitivity (accuracy). In either of these cases, the test can yield a false negative, which means it fails to detect the infection. And even then, the test can only function as a snapshot in time, so even a genuine negative test result today doesn't tell you anything about whether you'll be infected later in the day, tomorrow, or the next day. It is not a method of continuous, real-time disease surveillance.
A basic principle of infection prevention is that you do everything within reason to lower the probability of being exposed to an infectious dose of the infectious agent. As discussed above, there are various interventions that can lower the probability of contracting COVID-19—which is the essence of preventive medicine in general, and epidemiology in particular. For example, many of us take drugs to lower our cholesterol levels or blood pressure to reduce the likelihood of cardiovascular disease. Thus, our strategy is one of managing probability—more specifically, reducing the chances of your being exposed to an amount of coronavirus sufficient to penetrate your body's natural defenses and cause an infection. The more preventative measures, the better.
Monitoring for the presence of the signs and symptoms of COVID-19 is only minimally useful for preventing the spread of the infection. It is well established that the incubation period of the SARS-CoV-2 virus (the time from exposure to the virus to the manifestation of symptoms, such as cough, fever, shortness of breath, and fatigue) ranges from about two to fourteen days, with the average around 5 days. The shedding (or spreading) of the virus is at its peak during the several days before symptoms emerge and can continue for at least 10 days thereafter. And, according to the CDC, "If someone is asymptomatic or their symptoms go away, it's possible to remain contagious for at least 10 days after testing positive for COVID-19."
For these reasons, as touted in ubiquitous Public Service Announcements by U.S. Surgeon General Jerome Adams, the tried-and-true tetrad of masks, social distancing, hand-washing, and avoidance of crowds is all-important—but has been systematically ignored, and even denigrated, by many politicians and self-styled libertarian defenders of individual freedom. Now we're seeing, writ large, the costs of ignoring science.
Henry I. Miller, a physician and molecular biologist, was a Research Associate at the National Institutes of Health and the founding director of the FDA's Office of Biotechnology. You can find him online or on Twitter at @henryimiller.