michael barbaro

From The New York Times, I’m Michael Barbaro. This is “The Daily.”

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Today: Long before the world understood that seemingly healthy people could spread the coronavirus, a doctor in Germany tried to sound the alarm. Matt Apuzzo on why that warning was so unwelcome. It’s Thursday, July 9.

michael barbaro Good. OK, so we’re going to get started. camilla rothe Very good, OK. michael barbaro So you’re recording, right? camilla rothe Yep. michael barbaro You are recording, and I’m recording. So I think we can —

michael barbaro

Matt, tell me about this doctor in Germany, Dr. Camilla Rothe.

matt apuzzo

Yeah, she is a tropical medicine specialist, basically an infectious disease specialist. She’s at the Munich University Hospital. She’s at the infectious disease clinic there. And she’s part of this network of doctors around the world that serve as kind of like an early detection system.

camilla rothe We mainly work with returned travelers, as well as with migrants from tropical destinations and who may import even novel pathogens.

matt apuzzo

They kind of report back to major health organizations, like, hey, I’m seeing a weird virus over here, or Ebola case pops up over here, or here’s a weird thing.

camilla rothe In Germany, we are responsible for anything exotic.

michael barbaro

And so what prompted you to begin talking to her?

matt apuzzo

So January 27, this patient in Munich — 33-year-old employee from an auto parts company — walks into her clinic. And right away it’s pretty clear something weird is going on.

camilla rothe He informed us that when he came to work in the morning, he’d been told by his boss that a business partner who’d visited the company the week before, coming from China, had just phoned. And she’d said that on the weekend back home in China, she’d been diagnosed with the novel coronavirus infection. And he’d actually been ill over the weekend himself. And he’d asked us whether he could be checked for this new virus at our institution. michael barbaro And this was January 27, so had the coronavirus been detected in Germany? camilla rothe No, not yet. michael barbaro So what were you thinking when this man came into your office? camilla rothe Well, it was January. It was a time of year when there are lots of respiratory infections circulating. In fact, it’s the peak of the influenza season. And he’d been very unspectacularly ill over the weekend, so it could have been anything. In contrast, the pictures that we received from China by then were pictures of a very serious disease — people being on ventilators, et cetera. So I thought, well, I mean, interesting story, but this could be anything. And we took a swab from his nasal pharynx and sent it to the lab. And a few hours later, I was phoned by the lab and informed that, in fact, the test tested positive for the novel virus. michael barbaro Huh. So at this point, you have just been told that you have the first confirmed case of the coronavirus in Germany. And based on what you knew about the contact that had brought him to you in the first place, what were you thinking about that? camilla rothe That was quite a puzzle, because I’d obviously grilled him on the fact whether the Chinese business colleague appeared in any way ill. Had she coughed, or did she have a runny nose, or did she look ill in any way? And actually, he said she had held quite intense business workshops and meetings without showing any obvious signs of illness. And then on day two, which was the Tuesday, more employees of the company came to our clinic. And another three, all of them with very minor mild symptoms, were tested positive. That was the point when I thought, we need to spread the news to get this out to the world. And we contacted The New England Journal of Medicine, and they were interested. And it was very rapidly accepted and put online for people to read it.

michael barbaro

Matt, this paper that Dr. Rothe publishes, what does it find?

matt apuzzo

On the surface, it’s a really simple straightforward paper. It just says, we had this weird case with this guy who tested positive for the coronavirus, and the person he caught it from didn’t appear to have any symptoms. And that’s kind of weird because that’s not what we think is supposed to happen with this disease. So we thought it was important to just put it out there, and this could have serious ramifications. Just telling the world. In a nutshell, that’s all it really says.

michael barbaro

Well, help me understand that. For people who don’t work in the world of infectious diseases, what is the significance of this man’s diagnosis?

matt apuzzo

It’s funny. You look back now at the end of January, and it’s sort of like you’re looking at another time, another world. We’re still trying to find out what this disease is. And so the assumption kind of was, well, this is probably going to behave like SARS, because their genetic cousins. So good chance it’s going to spread like that. And the thing about SARS is, you don’t spread it until you are sick. Until you have symptoms, you are not really contagious.

camilla rothe So if a disease behaves like that, it is much more easy to control. It’s easy to define what a case is, who is a suspect case, someone who has symptoms. And if you ask these people to stay at home, you have already a good means to contain the virus. Now, if you have a virus that behaves differently, like what we had observed, which spreads before it even causes symptoms, this is much more difficult to control because people would never go for a test. They are not aware they are infected. They are mixing with people in the same way that they normally do — with colleagues, with friends, with loved ones. So it’s far more difficult to contain an infection like that. michael barbaro So this just flew in the face of the common understanding of the virus at that point. camilla rothe Absolutely. And then something strange happened that I personally don’t fully understand until today.

matt apuzzo

What Dr. Rothe didn’t know was that around 20 minutes away, in this sort of suburb of Munich, in the regional health office, they were starting up a command center basically to do all the tracking and the tracing and all of the stuff that needed to be done. And the doctors there were working on their own paper that they were going to get published in a different journal. And so now you’ve got two separate groups of scientists writing on the same case for different journals.

michael barbaro

And what did this group 20 minutes away, what did they find in their paper?

matt apuzzo

It’s really, really similar. So whereas Dr. Rothe says, this woman is not symptomatic — and she says that because this woman is leading two days of business meetings and she’s not sneezing, she’s not coughing. She’s not showing any signs of being fatigued or feverish or in any way sick. The government doctors, after extensive interviews, they come back and say, yeah, but we don’t think the Chinese patient had no symptoms. We think she was probably experiencing some symptoms that were so mild that even she didn’t recognize them. And so this dispute became, does she have no symptoms, or does she have such mild symptoms that even she doesn’t recognize that she’s sick?

michael barbaro

OK, so Dr. Rothe has published a paper saying that the patient had no symptoms. This government agency has now published a paper saying that she had early, essentially undetectable symptoms. So what’s the significance of that distinction?

matt apuzzo

So this has been the story of my life for the past however many months. The amount of time I’ve spent in conversations about the word “asymptomatic” or “pre-symptomatic” or “oligosymptomatic” or any of these words, right? What does it mean? If you are somebody who studies diseases, and you are somebody who really wants to understand the characteristics of this new virus, well, then obviously you want to know what exactly needs to happen before you can become contagious. Can you be just a passive carrier? Can you just walk around spreading this thing and you’ll never get sick? Is that a real thing that happens? Or does it only spread after you get symptoms? Or does it only spread when you have mild symptoms? That is a real distinction in the scientific world.

michael barbaro

Right.

matt apuzzo

However, from a practical standpoint of what you’re going to tell the public and how you’re going to control this disease, if you wake up in the morning and you’re like, aw man, my neck is kind of stiff, I probably just slept wrong. And then you go into work and you infect people, what does it matter whether you are pre-symptomatic, whether that neck ache was actually an early sign that you were getting sick and you just didn’t recognize it? If your strategy is, if you are sick, stay home, that all falls apart if you can spread this disease before you even know you’re sick.

michael barbaro

In other words, any version of not feeling sick is a huge danger when it comes to this virus.

matt apuzzo

Absolutely. Because it means, I don’t recognize that I’m a danger to you. And you don’t recognize that you’re a danger to me. And I don’t recognize that you’re a danger to me. And we all walk around and we don’t know that we can make each other sick.

camilla rothe Whether this person is ever going to be symptomatic or not doesn’t really matter. What the key message is, you can infect other people without knowing that you’re infected. I think the somehow sad thing is that this semantic debate — which is OK between scientists and so on, but it’s slightly splitting hairs — this debate somehow obscured the message we wanted to send out. And was somehow misleading, because it’s led us away from the core message to say, guys, keep your eyes open. This virus may spread without people knowing.

matt apuzzo

So this all would have been a kind of academic discussion between two groups of doctors in Germany. But at the beginning of February, a couple of days after Dr. Rothe’s paper came out, this thing completely escalated.

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And what happened was, Science Magazine, a very respected journal, wrote a story in which the German national health official said, Dr. Rothe’s paper is flawed. She never interviewed the woman. We don’t think she was asymptomatic. We do think she had symptoms. And now suddenly, this issue that might have otherwise been a very academic debate is now front and center in the national discussion over what exactly are the characteristics of this new virus.

camilla rothe We were accused of, how can you claim someone is asymptomatic when you haven’t talked to him? So if you like, this is formally a correct accusation, so the correct title could have been pre-symptomatic because the patient then developed symptoms at some point. But that was a slightly misguiding debate we were somehow sucked into then.

michael barbaro

And Matt, as best you can tell, is there validity to this critique from the government scientists of Dr. Rothe’s paper and her findings?

matt apuzzo

Yeah, I mean, I think there’s definitely a fair critique that she should have interviewed the Chinese patient before asserting that she had no symptoms.

camilla rothe Which, by the way, wouldn’t have been our role because we are physicians. It’s none of our business if anyone should have spoken to her, then the public health authorities of Bavaria. And they did. And they kind of summarized their phone call to say, she didn’t have any symptoms while she was in Munich. All she had was what she already knew as a feeling of jet lag and, well, the way you feel after a long distance flight. And she herself had not noticed anything abnormal to the situation until the Thursday when she’d returned to Shanghai and she fell ill, when she had chills and fever and cough and all that.

matt apuzzo

So as if this debate couldn’t get any bigger, it’s now going to go totally global because the world’s leading health organization, the W.H.O., is about to weigh in.

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michael barbaro

We’ll be right back.

matt apuzzo

So the morning of February 4, Dr. Sylvie Briand from the World Health Organization tweets the science article, and she says, “It is important to differentiate asymptomatic from pre-symptomatic transition. 2019-nCoV study claiming new coronavirus can be transmitted by people without symptoms was flawed.” And so now everybody who’s on the frontlines of this discussion is now basically saying Dr. Rothe got it wrong.

camilla rothe And that, of course, was disappointing in a way to see that even the highest-ranking somehow health authority didn’t get a very simple clinical message, but also got lost in semantics.

michael barbaro

Matt, why did the W.H.O. take the step of publicly disputing and criticizing Dr. Rothe’s finding?

matt apuzzo

I think there’s a couple ways to look at it. And one is that if you are the World Health Organization, and you jump in with two feet into this idea that this disease can spread without symptoms, it is a seismic change in the way we think about Covid-19, and has massive ramifications for public health policy in every country in the world. So of course, they need to be cautious. They can’t just go, oh my god, here’s an observation by one doctor with one patient, and we’re going to change the world’s policies based on that. That’s unrealistic. But what’s really confusing about all this is it didn’t take very long until it wasn’t just Dr. Rothe in Munich. Because the Bavarian health authorities get genetic information back, and they find genetic proof that it did spread before symptom onset in two other patients. And so now it’s not just Dr. Rothe saying, hey, I saw something weird. Now we have mounting evidence from this cluster saying, it’s pretty darn clear this is happening. And so now you really do wonder, why was the response from the World Health Organization, we don’t think this is a big deal? And not, boy, the evidence is growing, we’re not there yet, but we’re taking this really seriously. And we should maybe be start thinking about how we would adapt our policies if this really catches on.

camilla rothe I would have expected a very neutral and curious way and an open way, and to at least take into consideration that this virus might behave different than the other SARS virus that we knew. And that somehow didn’t happen. I don’t understand why it wasn’t. I still don’t understand. Maybe one day someone will be able to explain to me. I don’t know.

matt apuzzo

I talked to a lot of doctors about this. And there are many who say that you have to look at this from kind of a stark public policy standpoint. This is early to mid February. If you tell the world that this thing can spread before people are symptomatic, before they even know they’re sick, then the next question is, OK, so what do we do about it? We don’t have enough testing. We don’t have a contact tracing capability to handle this, and we don’t have P.P.E. for everybody. What do we do? We’ve talked to public health officials in other countries who said, yeah, looking back, we probably could have said, this is looking more and more like a possibility. But that’s a scary place to be if you don’t have an answer for what you’re supposed to do next, and that’s kind of where we found ourselves.

michael barbaro

I mean, I just want to wrap my head around this. Because what you seem to be saying is that there’s a possibility that embracing this finding is just too frightening for the people of the W.H.O., because of what it would mean for policymakers in every country of the world. But isn’t that the job of the World Health Organization to sometimes scare the crap out of people, even if there’s no logical solution to the scare, because they need to know?

matt apuzzo

So the W.H.O. says they definitely did not do that. That is not what happened. But this issue of should the World Health Organization or other public health officials be scaring the crap out of people, I mean, I get that. But I think most people would tell you no. Because there’s a huge danger in telling people, this is the big one, this is it. Because the vast majority of alerts aren’t the big one. You need people to take their advice seriously and rationally and not feel like, oh, here comes another alert. And so it’s like they got to constantly straddle this line between, I need you to hear me and take this seriously, but I can’t also get crazy and say, oh my god, oh my god, oh my god, this is the one, tbjs is the one. Because if it’s not the one — and most aren’t — then the next time, you’re just not going to listen.

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michael barbaro

Matt, what is the implication on the ground of organizations like the W.H.O. resisting this idea that there is symptomless spread? What does that actually mean throughout the world?

matt apuzzo

Well, I mean, so I’m in Belgium. And here’s a practical example. Belgium locked down nursing homes and said, you can’t visit if you’re sick. And thousands of people in nursing homes died. And they think that symptomless visitors and symptomless care workers brought the disease in, and they just had no idea that was even a possibility. We had the Diamond Princess cruise off the coast of Japan, where one of the reasons that people were allowed to mix and mingle and go to the buffet, even after a former passenger tested positive, was because, well, we don’t think he was symptomatic when he was on board. And then February 29, we get a tweet from the U.S. surgeon general, all caps: “Seriously, people, stop buying masks. They are not effective in preventing the general public from catching coronavirus.” And it’s hard to imagine the surgeon general weighing in like that if there was kind of a growing acceptance in the medical community that, boy, this might actually be spreading before symptoms.

michael barbaro

And of course, now we know that symptomless spread can be curbed, and a primary way to curb it is masks.

matt apuzzo

Yeah, and now good luck messaging that when you’ve been telling the public, in all caps, masks don’t help. As you look at these moments, it just cost us time. And that’s kind of the story of Covid right now. We lost time.

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michael barbaro

So, Matt, where does this debate stand at the moment? I mean, is there a settled understanding of whether or not, and how frequently, someone without symptoms can spread the coronavirus?

matt apuzzo

I think the best science now is people without symptoms are contributing to the spread of this pandemic. It’s significant. We don’t know exactly how significant it is.

michael barbaro

Mm-hmm. But it is clearly something that happens. And because it’s symptomless, it represents a special danger in this pandemic.

matt apuzzo

Exactly right.

michael barbaro

So that’s the public health consensus. But given everything that you have just told us, do you think that the public has reached that same conclusion? Has that message convincingly reached the world?

matt apuzzo

Well, the message is still a mess, right? I mean, we saw in early June, the W.H.O. came out and said, oh, symptomless spreading is really rare. And then they walked it back the next day. And part of what the W.H.O. is still doing is trying to draw this distinction between asymptomatic and pre-symptomatic, and it feels like we’re right back in February.

michael barbaro

Right. We’re making distinctions that don’t mean all that much to people who are trying to decide whether to go to work, whether to go to a restaurant, whether to see friends.

matt apuzzo

Yeah, and those are life and death situations right now. If I wake up in the morning and I believe that I’m not sick, and if the whole policy comes down to me understanding the difference between asymptomatic and oligosymptomatic and pre-symptomatic transmission, then the important message is lost. I’m putting other people’s lives in danger with my decisions.

michael barbaro

Matt, thank you very much.

matt apuzzo

Good to be with you.

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michael barbaro Doctor, if German authorities and European health officials and the W.H.O. had taken your findings seriously back in January, despite the fact that it was a single patient, despite the fact that there was a semantic debate around the title of the paper, how do you think it would have made a difference in the state of the pandemic today? camilla rothe Ha. That is very difficult to tell. It would be too easy, even though I would like to say that that could have saved hundred thousands of lives. Had authorities been stricter at an earlier point in time, well, would have people accepted it? This may sound strange, but maybe we needed the drastic pictures that we saw in Italy, when the military had to basically bury the coffins because nobody else could, or the dramatic pictures from New York City. Maybe that we needed, all of us needed that shock to take it seriously and really to pull up our socks to fight the virus. So it’s very difficult to tell what would have happened had we taken this onboard early on. matt apuzzo Has this experience changed how you see the global health community, your colleagues essentially? camilla rothe Oh, yes, definitely. Definitely. It was a very sobering experience. I still don’t know what to make of it. What I really hope is that someone is going to somehow work this up in a, again, in a scientific way to say, what happened? What happened in the heads of people? Why was this unwelcome news? Why was this dismissed? Can we learn from this? Is this, if you like, a cognitive error on the side of decision makers? And what can we do to prevent this from happening again? And I was, to be honest, deeply disappointed by it. But more so, I really wish to understand what was behind it. I’m really hoping that one day someone will come and explain to me what the issue really was.

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michael barbaro Well, Doctor, we really appreciate your time, and we wish you the best of luck. camilla rothe Thank you so much. Thank you.

michael barbaro

We’ll be right back. Here’s what else you need to know today. Amid intense pressure from President Trump to reopen schools, the U.S. Centers for Disease Control and Prevention said it would issue new guidelines to local school districts. In tweets on Wednesday morning, Trump described the original C.D.C. guidelines, which call for masks, social distancing, staggered arrival times and no meals in cafeterias, as, quote, “tough, expensive and impractical.”

archived recording (robert redfield) But I want to make it very clear that what is not the intent of C.D.C.‘s guidelines is to be used as a rationale to keep schools closed.

michael barbaro

A few hours later during a briefing at the White House, the C.D.C.‘s director emphasized that those guidelines are suggestions, not requirements, and said that he did not want the guidelines to prevent schools from reopening. And in a major ruling on Wednesday, the Supreme Court upheld a regulation from the Trump administration that lets companies with religious or moral objections to birth control limit coverage of them under the Affordable Care Act. The 7-to-2 ruling could result in as many as 126,000 women losing coverage for contraceptives from their employers. It was the latest case involving the relationship between church and state, in which the court’s majority has sided with religious groups.

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