Landon Donovan Wants to Sift Through the Coronavirus Noise
A few days ago I got a call from Landon Donovan, the U.S. men's national team legend who's now managing–and part owner of–San Diego Loyal in the USL Championship. He knows my wife, Dr. Celine Gounder, is an infectious-disease expert, CNN medical analyst and co-host of the podcast Epidemic. Donovan had questions, and I tried to answer them. But by the end of it, we thought it would make for a good Planet Fútbol Podcast to have Donovan ask the expert his questions about coronavirus.
The last time the three of us got together was for dinner in New York City the night before the final of the 2016 Copa América Centenario. This was a less festive occasion, of course, but it was insightful listening to the answers to Donovan's virus questions, which were very good.
One that stuck out was this one, when Donovan asked a straightforward question: Why were we not prepared for this?
The reply: "I don't really understand why people feel the need to prepare against human threats as opposed to viral or other biological threats ... Frankly, it really should be part of our national security agenda and priorities to be preparing for both. I mean, it would be like saying we don't need a military until the next attack. Obviously, that doesn't make any sense at all."
Below is the entirety of the conversation–and a huge thanks to Donovan and to Dr. Gounder for the informative discussion (edited only for clarity and length):
Landon Donovan: So I'm sick of hearing from people who don't know what they're talking about, and I wanted to hear from someone who knows what they're talking about, so I appreciate it. So I'll dive right in.
Does a person's level of fitness, health, wellness, etc, impact their ability to contract this and then also to fight it off or recover? So by being healthy or fitter, does that lower your chances of getting coronavirus? And then does it help you also fight it off faster? Is there any validity to that?
Celine Gounder: So there's sort of two pieces to that, Landon, you have the risk of being infected and then the risk of severe disease and death. So in terms of risk of being infected, that's really more a question of are you being exposed to people who have COVID-19 and to what degree are you exposed? So the group that's by far the highest risk for infection is healthcare workers, because basically all the patients in the hospital have coronavirus now and not just that. So not only are they being exposed over and over and over again, but the dose with which they're being exposed is much higher. Because if you think about when a healthcare provider cares for a patient, we get really close and the patient at that point is usually pretty acutely ill. So they might be coughing and sneezing and so on in a way that you're not going to see somebody who's just running in Central Park doing, even if they are a carrier of the infection.
The second piece is once infected, what is your risk of having severe disease or dying? And that's where your baseline fitness does matter. I don't know that I would say that being an elite athlete protects you that much over somebody who's reasonably healthy, but there's no question that if you have underlying heart or lung disease–in particular, those two–as well as diabetes and obesity, those do predispose you to more severe disease and increase your risk of death.
Landon Donovan: O.K.. And then you touched on something else. So I'm confused because is there a certain amount of you said like higher doses? I understand if you're more exposed on a daily basis, like a physician or a nurse or somebody like that is that you have a higher likelihood to get it. But do you get certain doses of diseases or certain amounts of it? Like, could I get a very, very mild strain of it and someone else get a much, much more potent strain of it?
Celine Gounder: It's not so much the strain, it's literally the amount of virus to which you're exposed. So if you think about you're exposed to one or two particles of virus versus a whole load of it, that actually does make a difference, because if it's a tiny amount your immune system has some time to recognize it, respond to it, mount a response before the virus has had too much time to replicate. Whereas if you get a big dose, your immune system doesn't get that kind of head start. And again, this is why even young, healthy healthcare workers have had severe disease, because they're basically getting a big dose all up front. So they don't have sort of that time for their immune systems to react the way that the average person may have that chance.
Landon Donovan: I told you I'm going to jump around, and I'm literally just jumping around this sheet of paper. There's a ton of big questions, but why were we not prepared for this? I mean, I'm not an expert. So in the beginning I was saying things like, well, it's in China, and so was SARS and so were other things. But it never made its way here. It wasn't that big of a deal. But aren't there people paid, and isn't this why we pay so many taxes, especially in California and New York, so that we're prepared for things like this?
Celine Gounder: Yeah, that's a huge question, and there's different ways to answer it. So first of all, for those of us who work in this space, we have been saying literally for decades that this was something that we needed to worry about. We were more worried about a pandemic influenza that was going to behave in exactly this way than specifically a coronavirus. But the premise is essentially the same in terms of what you need to be preparing for in terms of things like the national stockpile, in terms of drug and vaccine development and those kinds of issues.
I don't really understand why it is people feel the need to prepare against human threats as opposed to viral or other biological threats. That's one I don't understand, because, frankly, it really should be part of our national security agenda and priorities to be preparing for both. I mean, it would be like saying we don't need a military until the next attack. Obviously that doesn't make any sense at all. And frankly, this was under certain administrations recognized to be a national security concern. After Ebola, there was a position on the national security council focused on pandemic preparedness. And John Bolton and this current administration dissolved that. I don't know that that would've solved everything, but it certainly would have put us in a slightly better position to prepare for the current situation.
Landon Donovan: O.K. And I apologize if these are really dumb questions, but why didn't Ebola or MERS or SARS or H1N1, why didn't they take off the way this has?
Celine Gounder: Well, some of this is a reflection of how infectious it is, how it's transmitted and then how deadly. So Ebola doesn't spread as easily as coronavirus. Ebola is really something that's spread by contact with infected fluids, but it's not spread through the air. Whereas coronavirus, if you're coughing or sneezing and somebody is in the vicinity, it's going to be transmitted to somebody. That's why the six-feet rule comes in.
Now MERS and SARS are also coronaviruses like COVID-19. They are transmitted similarly. They seem to be relatively less transmissible as compared to COVID-19. So while the route of transmission is essentially the same, the probability of transmission is lower with SARS and MERS. And then the other piece of it is how likely is it to kill you? So if something is extremely fatal, like Ebola, it's actually much harder for it to spread through the population, because people die from it pretty quickly, and they're not able to spread it. Whereas with coronavirus, we're actually realizing probably about a quarter of people who get it don't have any symptoms at all. And then another big chunk have very mild symptoms. And those people can be spreading this, and they themselves really don't suffer major consequences, but other people to whom they spread it to may. And so that's also a big difference here.
Landon Donovan: So it leads to the question, and maybe this is something you shout from the rooftops all the time, but shouldn't we kind of be social distancing like forever anyway? I mean, do we really want to be exposing ourselves to any of this stuff all the time?
Celine Gounder: Well, I mean, I think social distancing forever is pretty radical. I think we do need for the foreseeable future to be very focused on very strict social distancing. We're looking at probably a couple months here of that. And it's also going to be sort of in waves where essentially what's happened is New York City being the biggest, densest city in the country, and then some of the West Coast cities like Seattle, San Francisco and L.A. are sort of at the front end of this curve where those West Coast cities also have tighter relationships with China and other Asian countries, both in terms of business and travel. So of course those are the places that are going to be hit first.
And then now we're seeing sort of a second wave with midwestern and southern cities like Detroit, Chicago, Atlanta, New Orleans. And then it will go from there to other such cities in the Heartland, as well as suburban areas and then rural areas. And so suburban areas: we're already seeing here outside New York City, places like Bergen County, Westchester County, and even places as remote as the Navajo nation is seeing cases now. So it's kind of trickling from the biggest, most populous, highest-risk places into the rest of the country. And so there are certain regions that may go through the social distancing phase with a very tight lockdown first, and then be able to move into the next phase of containment, which I can describe in a moment, after that, while other parts of the country may still need to be under lockdown.
Now what does life after lockdown look like? What you really want to do is get to the point where there's not so many cases in the community. When you have many fewer cases, you're actually able to do contact tracing, which is where if you take person a who has a disease, can you trace the person B and C that they have infected, and then be able to say, O.K., person C has infected person D and E? Right now we can't do that, because there's just so much transmission that those chains are completely blurred. But once you get it suppressed enough that you can start to do that and complement that with testing, it becomes a very different thing to control. So that would be sort of the next phase in all of this. So I think once we get to that point, we won't need to do social distancing the way we are now.
Landon Donovan: So to that end, and I don't know if this was planned or if it seemed like it was more reactionary, from our government and even our local governments, we went through O.K., no mass gatherings of a thousand-plus, no mass gatherings of 250, no mass gatherings of 10 and then it was basically self-isolation. So when you come out of this, is there a similar sort of easing back in? And it leads to my bigger question: When will we be able to have sporting events again in front of fans? And I know you don't have a definitive answer, but is there a process that we go through to get back to normal life? Or is it just one day we say, O.K., we feel good about it. Everyone can get back together now.
Celine Gounder: I think those initial cutoffs were very arbitrary, frankly. They were not science-driven. A lot of that was more sort of like, well, we know we need to do something, and this is what we think is politically or socially palatable. I think it's really much more what I was describing earlier: to get transmission suppressed to the point where we can trace chains of transmission where we have enough testing available. And then we can just really lift these social distancing measures.
The other piece of that is there are antibody tests that are being developed, which is different from the tests available right now. So the tests we have right now really detect the genetic material of the virus. So it tells you, is the virus, at least the genetic material, in the person's body right now? So we use that more to figure out, O.K., you have a cough, you have shortness of breath. Is that because you have coronavirus? Is that from another pneumonia? Is that maybe from emphysema or heart failure? So that's how we're using the test right now. It doesn't tell us anything about, did you have it a month ago or two months ago? It doesn't tell us if you're immune. And so the antibody tests that are in development right now that hopefully we'll have available soon, will tell us, did you have it a month or two ago? And are you immune now? And so that's really important for this second phase, because that's when you can also be more targeted in terms of who do you sort of shield from exposure and who can you say can go back to work?
So if you're antibody positive, you should be able to go back to work. You're not going to get infected and have severe disease. And also very importantly, you're not going to help transmit the disease in the community.
Landon Donovan: Right. So we could literally say like, here at SD Loyal with the front office staff or with our players, everybody takes a test and those who have the antibodies are immune to it already and can go back to work. But then what happens for people who have not had it, are not immune to it? I mean, you don't want them going back out in the world.
Celine Gounder: And so those are the people that may need to continue doing isolation and the social distancing thing. There's been discussion, well, what about just letting young, healthy people go back to work? The problem with that, there's two problems. One, some of them will get very sick. Some of them will end up on ventilators and some of them will die. So that's a very crude way of deciding what's your risk. The other problem with that is that they can contribute to ongoing transmission in the community. So really having an antibody test to make that differentiation, who needs to continue isolation, who doesn't, that is a far more useful and safe way of doing that.
Landon Donovan: O.K. But that's confusing to me because let's say everybody on my team has been exposed to it, is now immune to it, but I am not. Isn't the point then to become immune to it because I can't self-isolate forever, because at some point I need to be exposed to it so that I can become immune to it. So I have to wait until there's a vaccine in a year before I can leave my self-isolation?
Celine Gounder: I mean, potentially, yeah. That's what we're looking at.
Landon Donovan: Don't tell me that.
Celine Gounder: And then there's also going to be a discussion, like if you were saying, 'Well, my entire team except for me is immune.' That basically means you have the herd immunity of the team that's protecting you. So, you know, I think these are going to be more nuanced discussions of, 'Well, if everybody on the team except Landon is immune, and we can assure that Landon is not exposed to anybody outside the team, is there a way to make it safe for Landon to go back to [coaching]?' So I think there's going to be sort of a balancing act to be done. But I think especially people who are not immune and who fall into very high-risk groups and who are in places where there's ongoing transmission ... those people absolutely are going to have to keep self-isolating until there's a vaccine.
Landon Donovan: I want to get back to something you said earlier then. And this is where my thinking has evolved. If we can save one life, it's worth it, right? And in the beginning it was kinda like, 'Well, it's just like the flu and a lot of people die of the flu.' So that's like a crude way to say it, but it's the reality. But as a human being, if you can save one life, it's worth it. But back to the social-distancing thing. If this is the case always, and when this goes away or when there's flu season, shouldn't we not be trying to spread anything to anybody? I mean, isn't that the goal? To save at least one life? So why wouldn't we just do it all the time?
Celine Gounder: Well, this is where the CDC has been contemplating whether to recommend that everyone wear some sort of face covering. And there are Asian countries in which people do that, and they also do that in part because of pollution. But there's more of a culture of in the winter you do cover your nose and mouth, especially if you are sick. And so I think that may in fact potentially be a lasting impact of this on our social norms where during cough and cold season we do wear some sort of face covering. And it doesn't need to be for that purpose when you're just trying to prevent transmission from yourself to others. That doesn't need to be a medical grade mask. That could just be a scarf or bandana or whatever it is, as long as it's covering the nose and mouth. And so that I think would be a very positive development because it would help prevent not just transmission of coronavirus, but also influenza and other cough and cold viruses.
Landon Donovan: O.K.. One question that is very pertinent to us in what we're doing. Would you, in your professional opinion, assuming let's use a scenario where everybody on both teams, a team we're on and a team we're playing against, had developed immunity or had developed the herd immunity, or was, you know, let's just say "safe" at this point. Would you, in your professional opinion, recommend and say that it's O.K. for us to be playing games in front of empty stadiums at some point, let's say that's two weeks, four weeks, six weeks, eight weeks, whatever. Would you say that that is a safe thing to do?
Celine Gounder: Well, a couple things. One, how do you function as a team? Are you a bubble of your own? Probably not, because I assume people have significant others and children and so on. That's where it becomes very difficult to control the risk within a team. If you could guarantee that everybody on the team was not having contact with anyone else from the outside world during some set period of time so that you can prevent any infection from penetrating sort of that team group, that would be a way of restarting play sooner.
Landon Donovan: So I can speak for every parent in America. We would happily be isolated from our children right now for awhile [laughs]. So I think we can get that done. Probably our significant others too. A couple more questions and I appreciate you taking the time. I have some very smart friends who see both sides of this coin. And I want to be careful about how I word it, but I think there is a reality to it. So I think you're aware that when the economy hits a certain point negatively, people actually die, right? So how do we as a society balance people dying from COVID-19 and what that looks like versus how we are impacting our economy long-term that will lead to suicide, people dying literally of starvation, getting kicked out of their homes, being kicked onto the street, homeless, etc. I hear Governor [Andrew] Cuomo say, I think I've heard you say it. I've heard others say it, the only way to get the economy back is to get everybody healthy, which I understand and can appreciate, but there are people who, when I go to the grocery store, I know there are people who have to work or else they will not survive. So how do we balance that?
Celine Gounder: I think to your point that this idea that there are people who have to work because otherwise they won't survive, you're exactly right. And that's part of the problem we're seeing right now. Why was Elmhurst hHospital in Queens the hospital hit hardest by all of this in New York City? It's because it serves a community where it's people who work in service jobs. So these are the people who drive cars, who are nannies or housekeepers, or food delivery people, or food preparation folks, restaurant workers and so on. And they don't have a choice.
And I think this is where, if we want to also blunt some of the economic impacts in order to really achieve the necessary social distancing as soon as possible, we're going to need to help people at that end of the socioeconomic spectrum so that they can adhere to social distancing. The longer social distancing needs to be implemented, the greater the damage to the economy. And then on top of that, the long-term effects that you're talking about in terms of what's the impact of the economy on people's health. It's also at that end of the socioeconomic spectrum that people are going to suffer the most. And we've already seen this in terms of increasing rates of suicide, who's most affected by that in the U.S. that's essentially poorer Americans. So that's who this is going to affect. So if we're concerned about that, that is where we're going to have to do some sort of redistribution of resources to address that and to support people through what is going to be probably a very difficult couple years after this.
Landon Donovan: O.K., last question. I really appreciate your time. Thank you. What in your opinion is the most urgent important thing for us to know or do or help with, right now? A lot of people feel helpless. And so if it's absolutely social distancing is the No. 1, or staying isolated, or if it's sending masks to hospital workers who need them, or PPE [personal protective equipment] to people who need it, what is the one thing that is most grave that people can help with or do to help?
Celine Gounder: Well, I think it's exactly those two things that you just cited, Landon. I think one, really taking social distancing seriously, really committing to it, trying to put pressure on family and friends to also do it. This is a real problem. This is not a hoax. And so I think that's No. 1. No. 2, don't log on Amazon and try to buy up PPE, you are just going to drive up prices even beyond what they are now. But if you have some in your home, if you know friends or family who have it, have them donate that to the hospital, because it really is a very dire situation that we're dealing with right now. And we are seeing nurses and doctors getting sick from this. Which is a real problem, because if they get sick, that means you have that many more people having to call out from work, that many fewer people available to take care of patients. So I think those are really crucial.
And then finally, you know, give to social service programs that are really trying to help the most vulnerable. So some of the people we were just talking about, people for whom just getting a meal might be a challenge now. And there are a number of organizations depending on where you live, that really are trying to do that. So I would say if you can write a check to help one of those local organizations, that would really have an impact as well.
