2 August 2020 – Sunday – #106

On Friday, I looked at the Covid-19 new infection numbers in Catalonia. They were leveling off. Not as much as I’d hoped, but it seems that the government’s re-imposition of restrictions is keeping Covid-19 at bay for now.

I decided to go ahead with a planned visit to friends in Canet de Mar yesterday. Such are the risk assessments now associated with travel.

The Catalan health authorities seemed to agree with me. They lifted some restrictions in Barcelona and Lleida that they’d put in place to avert a second wave of Covid-19.

Spain, however, is not out of the woods. Between seasonal agricultural workers with poor living conditions, youthful bar hoppers, and tourists, two of the curves below are headed in the wrong direction and the third will turn up soon.

Spanish Covid-19 confirmed cases, hospitalizations, and deaths through 22 July. Source: El País,

The good news making travel decisions is that Spanish Covid-19 data should be more accurate now. Unlike three or four months ago, the healthcare system isn’t swamped and testing capacity is up. The Spanish Covid-19 death toll has been revised up to 44,868 after the government had time to comb through its data. With better data, the question is what data to use when making decisions to travel. Or even just to leave the apartment.

Brad pointed out, for instance, that there are data for each health jurisdiction. I had two reasons not to use that data when I decided to take the train to Canet de Mar. The health jurisdiction data do show local hotspots to avoid, but they are also probably at least two days out of date. So, you could decide it was safe to travel somewhere only to find out two or three days later that the safe place you visited turned into a hotspot while you were there.

Systematically, the agency that controls my Covid-19 health is the Catalan public health authority. Covid-19 outbreaks are bound to flare up here and there, so the real question is not whether I can identify the safe places to go by local data, but whether my Covid-19 health authority has the right systems in place to manage these outbreaks. In other words, since I’ll never know for sure if I’m headed towards a hotspot, looking at the Covid-19 situation in all of Catalonia is a better gauge of whether my health authority has the right systems to keep me safe.

Speaking of travel decisions, Brad is on a flight from SFO to CDG as I type. That comes with all kinds of risk assessments. He had a negative Covid-19 test last week, but it’s not clear whether that helps either clearing customs or quarantining once he arrives at Casa Solar. Both of us are pretty sure that he can clear immigrations with the long-term visa no lucrativa in his passport. His bags have been checked through to BCN, so it’s not clear whether he will clear customs in Paris (will the French honor a Spanish long-term visa?) or in Barcelona. Nicole says he clears customs in Paris and his bags clear in BCN. I’ll have updates next week. [UPDATE: Brad’s through immigrations at CDG and at the gate for his flight to BCN].

The big Covid-19 news this week are Q2 economic results. Spain’s economy contracted 18.5% quarter over quarter. The US economy contracted by 9.5%. By comparison, the EU economy contracted by 12%. The largest economy in the EU is Germany whose economy contracted by just over 10%.

Sweden is the EU country that attempted less heavy handed Covid-19 restrictions. The Swedish economy contracted by over 6%. That looks good compared to the EU, but Sweden’s neighbor Denmark, which had strict Covid-19 restrictions, is estimated to see its economy contract about the same amount.

The enormity of these economic contractions has to change the world. Things limped along in the second quarter, but I expect big ticket items like mortgage defaults and rental evictions to start breaking significantly in this quarter. The good news is that governments seem to be loosening their economic policies instead of tightening them, as was the case in the 2008 economic meltdown. The hard work is getting economies moving again.

The economic advantage the EU has over the US is that it can open up most of its economy as long as it contains Covid-19 outbreaks. The US, on the other hand, has seen the first wave of its Covid-19 epidemic rebound. US Covid-19 deaths are back above one thousand a day and, if unchecked, the US will have the worst per capita Covid-19 death rate in the world by election day. The extended first wave of Covid-19 will keep the US from fixing its economy.

Which brings me back to my Canet de Mar visit.

View of the Mediterranean Sea from the Canet de Mar train station, 1 August 2020.

I took the train from Barcelona. The ride there was less crowded than the ride back because everyone leaves the coastal beaches about the same time to return to Barcelona. As with my recent trip to El Masnou, pretty much everyone was wearing a mask. There was the couple sharing a kiss, though. That’s an awkward situation.

Part of the discussion with my Canet de Mar friends was about how much better things seem to be working in Spain right now. Everything, and I mean everything, is politicized in the US.

In Spain, people wear their masks. Occasionally, I count the people wearing masks along a random block in Barcelona. The counts this week have been well over 90% wearing masks, up from even the end of the lockdown.

In the US, people are breaking other people’s legs, stabbing each other, and peeing on the floor because they don’t want to wear masks. Even after conservative icons Bill Montgomery and Herman Cain died of Covid-19, even after Rep Louie Gohmert may have infected Rep Raúl Grijalva during a committee hearing, even after the science shows Covid-19 is spread by aerosols, conservatives cannot brook masks. “Give me liberty and give me death” seems to be the new conservative slogan.

In Canet de Mar, Tony told me, the locals made sure to support the town’s businesses during the lockdown. It looks like all the restaurants will stay open. Most of them have added abundant outside dining areas. There’s even a new place to try vermut and several new bars along the beach.

After almuerzo, back at Kim and Conie’s place, we sipped cava and surveyed the beaches, which now fly blue flags. There was speculation that the cessation of cruise ships helped the beaches qualify for blue flags this year. Natalie said the quality of the sea water was definitely better during her swims.

All of us wondered why the US can’t get its Covid-19 act together. If Trump decided tomorrow that the only thing that mattered was beating Covid-19, he could shut down the US again for four weeks and have two months to campaign on a great success.

Maybe it’s always nice in Canet de Mar, but if the only thing I have to do to earn a tasty lunch and bubbly on the terrace afterwards is wear a mask, I can wear a mask.

For my friends in the US, here’s how things look from outside.

Wear a mask, keep your distance, and wash your hands. It will go away without vaccines or treatments.

I’m blogging weekly on this page and tweeting daily here. I’m working on a mailing list and apologize for last Sunday’s pilot error sending out a blank email.

26 July 2020 – Sunday – #105

Covid-19 curtailed my travel plans for 2020. I wasn’t alone. As Covid-19 continues on and on, my travel plans continue getting smaller. I’m not alone in this, either.

In March, Mom and I were discussing when I could visit her later in the year. By the middle of the lockdown in April, it wasn’t looking so good for any 2020 travel to the US with nearly all international flights grounded. When Spain lifted lockdown restrictions, I decided my safest bet was to think smaller, to use the rest of 2020 to explore Catalonia and nearby cities like Madrid and Valencia.

To paraphrase an old saying, when you make plans, Covid-19 laughs.

Covid-19 is back in Spain. Cases rose after the restrictions were lifted. A lot. Last week Barcelona reverted to Phase 2 of the lockdown relaxation. I cancelled a trip to Sitges and reduced my 2020 travel plans once again, limited now to the exploration of my new hometown. I”m still not sure what I’ll do about a planned trip to Canet de Mar next weekend. It’s a small city where friends live about an hour by train up the coast from Barcelona.

So far the Covid-19 resurgence here doesn’t look nearly as bad as Israel’s second wave or the extended first wave in the US. It’s not clear, though, whether Spain is on the brink of a second wave or just hasn’t got its public health act together. Public health seems to know where the outbreaks are taking place, which is a big step forward from March. My opinion is that with some quick staffing of public health tracers, Spain can get the lid back on the Covid-19 jar.

The resurgence is closing the doors of hotels and restaurants before Spain’s travel industry had a chance to reopen them completely. Catalonia’s already depressed hotel reservations dropped 20% after France asked its citizens to forgo Spanish beach vacations. The UK has imposed a 14 day quarantine on travelers from Spain, effectively shutting down a fifth of Spain’s tourism

We should know next week whether the macro orders to revert to Phase 2 are compensating for the lack of case-by-case tracers. Covid-19 will let Spain know.

This week is a strange juncture of bad Covid-19 news and good Covid-19 news.

The bad news is that the US, the country with the world’s dominant economy and the world’s best science, technology, and high tech resources, has screwed up its Covid-19 response royally while smaller countries, countries Trump referred to as “shithole” countries, have had among the best responses. Think countries like Vietnam and Rwanda.

The bad news is that Covid-19 is spreading through the less developed world and overwhelming many of the largest less developed countries. Think countries like India and Brazil.

The bad news, and the reason this is a strange juncture in the Covid-19 timeline, is that all the good news probably won’t change Covid-19 outcomes meaningfully until the end of 2020 (for therapies) or the end of 2021 (for vaccines). In other words, the relentless bad news of Covid-19 will be with us for a year or more.

The good news seems very good right now. Bill Gates summarizes vaccines and, to a lesser degree, therapeutics in this interview.

Bill Gates summarized current state of Covdi-19 vaccines and therapies.

On vaccines, the good news boils down to the very low regulatory approval bar of 50% efficacy for the first Covid-19 vaccines. That moves some health benefit into the market early, but probably means multiple Covid-19 vaccine shots until a second, more effective generation of Covdi-19 vaccines hit the market, presumably in 2021.

The big caveat, of course, is that even though the candidate vaccines are generating the kinds of immune system responses scientists expect from a vaccine (antibodies and T-cell), we don’t know for sure that any of the candidates provoke the right immune system response to immunize for Covid-19. With 20+ vaccines in human trial, large numbers are working in everyone’s favor.

Assuming the anti-vaxxers don’t throw a wrench in the works, that means the US and EU could have enough vaccine to achieve herd immunity later in 2021. The rest of the world probably achieves herd immunity after that. We need herd immunity everywhere to thwart Covdi-19.

On a related note, the good news is that herd immunity will happen, I’m going to note (without citation because I’m being lazy) that it looks like, regardless of what you may have seen about Covid-19 antibodies dropping off, patients’ T-cells are doing the expected things to establish long-term immunity. That means Covid-19 herd immunity is likely with vaccinations. The best proof I have for this is that immunologists aren’t running around like chickens without heads saying we can’t achieve herd immunity. They are saying the opposite.

The good news in the Covid-19 therapeutic landscape falls into two basic categories, monoclonal antibodies and repurposed drugs.

Several monoclonal antibodies for Covid-19 started phase 1 trials earlier this month. Big pharma production goals are tens of thousands or low hundreds of thousands of doses by the end 2020. Those are small numbers compared to Covdi-19 vaccine doses, but the main application is for people who are, or who are suspected of being, sick, not for the 60%+ of the population needed for herd immunity.

The repurposed drug category is much less predictable than monoclonal antibodies. In addition to the antiretroviral Remdesivir and the corticosteroid dexamethasone, which both are being used currently for Covid-19 cases, a new study shows that inhaled interferon significantly improves Covid-19 outcomes. Separately, a retrospective study shows that intravenous immunoglobulin (IVIg), a drug used for immune system disorders, improves Covid-19 outcomes in severely ill patients. I don’t mean this list to be exhaustive. UCSF, for instance, started a program in March to identify candidate drugs for re-purposing. That means there are probably many other studies coming to fruition in the next months.

So, there is the good news. It looks like the treatments and vaccines are coming. We even know about when they will arrive, which is better than my travel planning. That’s great unless Covid-19 complacency sets in. It will be easy to say, hey, why bother with lockdowns when there will be better therapeutics in six months.

Trump already gave an example of how he uses Covid-19 complacency in last week’s interview with Chris Wallace. After Wallace lists many incorrect statements Trump made about when Covid-19 would go away, the two men have this exchange.

TRUMP: I’ll be right eventually. I will be right eventually. You know I said, “It’s going to disappear.” I’ll say it again.

WALLACE: But does that – does that discredit you?

TRUMP: It’s going to disappear and I’ll be right. I don’t think so.


TRUMP:  I don’t think so. I don’t think so. You know why? Because I’ve been right probably more than anybody else.

Fox News, “Transcript: ‘Fox News Sunday’ interview with President Trump,” 19 July 2020.

Trump’s Covid-19 argument always has been that it’s going away, so why deal with it? It’s an excellent con because people want to believe they don’t have to change their Way of Life. Trump’s Covid-19 argument will resonate more when he notes a vaccine is around the corner. If nothing is done until the vaccine comes, he fails to mention, more people will die.

The implication of Trump’s insidious argument is that, after you’ve lost 150,000 American lives, what’s another 150,000 while we wait for a vaccine? “It’s going to disappear.”

I want to end today with a few Big Thoughts on Covid-19. What triggered this big thinking, in part, was a New York Times article in which the author describes how Covid-19 has replaced any notion he had of hope with a sense that the best he could hope for during Covid-19 is to explain what happened. Covid-19 has forced him to contemplate his death every day. That has changed his perspective on life.

Covid-19 is a truth teller. It reveals truths about our society, our morals, our institutions. As we reach this weird juncture where the end is in sight, but the Covid-19 pandemic is still raging, here is a short list of topics that Covid-19 asks us to consider.

  • Capitalism and Free Markets. Capitalism has failed in many ways during Covid-19. Here are a few examples. Covid-19 created enormous spikes in demand for PPE, ventilators, and other equipment that free markets couldn’t supply. Hospital bed supply ran out. Moving work space from office to homes created discontinuities in supply chains and shortages of not only, as everyone remembers, toilet paper, but also food. The employment discontinuity broke food and housing markets. The structure of US markets failed to allocate correctly medical care, housing, and food people need to live. If the economy isn’t working to help people live in the middle of a pandemic, who is it working for?
  • Democracy, especially US Democracy. The US democracy has a single point of failure in the executive. The executive ordered measurably among the worst Covid-19 responses in the world, a response that provided few standards, little guidance, and almost no coordination. Administration decisions consistently drove up costs by asking states to bid against each other. The allocation of responsibility for reopening to US governors didn’t come with the standards (including enforcement) they needed to make good decisions. Governors formed regional councils when the federal government failed. How did the US governmental system lead to one of the worst Covid-19 responses in the world? If the government isn’t there to protect residents during a pandemic, why is it there?
  • Media and Misinformation. I don’t have time. In a nutshell, traditional and social media are creating an epidemic of misinformation. Why?

This weird juncture between good news and bad news is a critical time to evaluate these topics. The world will face more Covid-19 type of discontinuities. Pandemics are increasing with higher human population and climate change. Then there’s climate change itself, whose scale will put the Covid-19 pandemic to shame. I don’t know how the world addresses these issues, but they are issues that we will face again soon.

19 July 2020 – Sunday – #104

I was planning to travel to Sitges this weekend. Ana recommended a paella place. I’m dying to try the different kinds of Spanish paella. A friend was all set to join me. On Friday, at the very last second, just as I picked up the phone to test my Spanish skills making a reservation at the paella place, Covid-19 laughed.

As expected, Covid-19 cases are up in Spain after the lockdown. Unfortunately, they’re up a lot in Catalonia. So, Barcelona is reverting to Phase 2 of Covid-19 restrictions. No one’s exactly sure what that means. For instance, is the beach off-limits now? But the signal is clear that we need to change our behavior. So much for my summer travel plans. I’m dying for paella, but not enough to actually die.

The first large Covid-19 outbreak here started among seasonal agricultural workers in Lleida. It’s clear that there were not enough contract tracers to follow up on all the cases.

“Germany has calculated its contact-tracing staff needs very well. It has figured out that it needs around 25 tracers for every 100,000 inhabitants. Catalonia would need between 1,500 and 2,000.”

Magda Campins, epidemiologist and chief of Barcelona’s Vall d’Hebron Hospital, El País, “Barcelona hospital chief: ‘The situation in Lleida has clearly gotten out of hand,” 14 July 2020.

At the rate Germany recommends, Catalonia should have sent over 100 contact tracers to the Lleida region. It sent nine.

Now infections in L’Hospitalet, on the west side of Barcelona, are on the rise as well. Michael Bennett graphs the Catalonia cases before and after the New Abnormal started (green vertical line).

Covid-19 cases in Catalonia ending 16 July 2020.

Catalonia’s failure to provide Covid-19 contact tracers is especially problematic because of asymptomatic cases. Researchers recently have found that a large proportion of Covid-19 cases are asymptomatic.

Asymptomatic Covid-19 cases increase likelihood of spread.

The blue area above shows the presymptomatic cases, red area the confirmed Covid-19 cases. In between blue and red, the yellow area shows cases that are hard to determine. It’s clear that most people don’t know they have (or they are about to have) Covid-19. That, by the way, is why it’s important to wear a mask even when you feel okay.

Young people are more likely to have asymptomatic cases. This heat map of the progression of Covid-19 cases in Florida shows how young people help spread the virus.

Spread of Covid-19 in Florida by age.

The horizontal axis is time and the vertical axis is age. Each square represents Covid-19 infections during a four day period for an age group of five years. The brighter the square, the higher the infection rate. The chart shows how Florida’s current Covid-19 outbreak started with young adults in their twenties who probably had asymptomatic Covid-19 cases. That hot mess then spread Covid-19 to older Floridians. There is no reason not to think the same kind of spread is taking place in Catalonia.

How bad can the asymptomatic spread of Covic-19 get? In Australia, contact tracing is working and it’s uncovering just how bad a superspreader case can be. An asymptomatic Australian woman with Covid-19 did everything right after travel, but one elevator ride apparently infected 71 people.

One asymptomatic carrier rode an elevator alone, then 71 people got COVID-19. She did everything right. She had no symptoms, but she self-quarantined anyway after travel. She stayed in her apartment. She ordered-in food. But she became patient zero in a 71-case cluster.

News.Com.AU, “Coronavirus contract tracing: Woman infects 71 people in 60 seconds,” 13 July 2020.

With high asymptomatic spread, it’s clear why masks are so important: to stop aerosol spray from asymptomatic cases.

For any skeptical readers, here is a story from The Department of Masks Really Work Department. Montgomery, Alabama is a poster child for cutting the spread of Covid-19 with masks.

Montgomery Mayor Steven Reed explains drop off in Covid-19 infections due to mandatory masks.

Really, the Montgomery story should be enough. But here’s an encore mask story for anyone who gets a hair cut.

CDC reports effectiveness in masks preventing Covid-19 spread at hair salon.

Good news on vaccines. First, the Covid-19 vaccine candidates furthest along in testing are eliciting the immune system responses needed to make a vaccine work.

“The results from Oxford yesterday add some detail to this discussion, with the good news that the two most obviously key parts of immune protection are effectively induced: antibodies that can neutralise virus entry, and T cells that can recognise and attack infected cells.”

Danny Altmann, Professor of Immunology, Imperial College London, The Guardian, “Covid-19 vaccine: what have we learned from Oxford phase one trial?,” 16 July 2020.

The questions for each of the 20+ vaccine candidates in human trials are whether they are safe and whether the particular immune system response they elicit will stop Covid-19.

Second, a Singapore study measures CD4 and CD8 response to the NP (nucleocapsid protein) fragment of the SARS-Cov-2 virus, which demonstrates immune system response and confirms SARS-Cov-2 vaccines should work. The study also found memory T-cells from the 2003 SARS-NP virus, which indicates that the immune system has created memory T-cells for other SARS viruses.

Eric Topol explains how this study helps, but doesn’t quite fill in all the gaps in our knowledge of Covid-19 and vaccines.

A look at what we know about Covid-19 and the human immune system response.

Big Pharma is gearing up to deliver vaccines even before they complete trials. Pfizer expects to deliver 100 million doses this year and a billion in 2021. It looks like we’ll be injecting something in the next year or two, but no one is quite sure what.

Whether vaccines will work against Covid-19, however, is not settled science. One doctor documents a recovered Covid-19 patient who had two negative PCR tests and then developed a second case of Covid-19. Because this is a well documented case, it shows that Covid-19 re-infection has happened. The open question is how often does re-infection occur. Is everyone susceptible to Covid-19 re-infection after a time? Or is it a one-in-a-million occurrence?

Many studies are showing Covid-19 antibodies disappearing altogether a few months after infection. Memory T cells may form for Covid-19, but that isn’t known, and, if they do, it also isn’t known if they will be effective against future infection.

All this may mean we will need booster shots for a vaccine. It certainly shows the need to continue investigating other therapeutics like monoclonal antibodies in case vaccines don’t provide the immunity needed.

It’s also important to note that New Zealand eradicated Covid-19 last week. Our kiwi friends have shown it’s possible to beat Covid-19 without treatments or vaccines if public health can do its job and people cooperate.

There are many signs that the US push to reopen is a disaster. The clearest is rising Covid-19 deaths. To paraphrase Paul Krugman, Americans needed a drink and now they’re paying the tab.

There are also many signs that the US push to reopen isn’t benefiting the economy as much as if the country had waited until Covid-19 was under control to reopen. One such sign is 5.4 million Americans losing healthcare insurance in the middle of a pandemic. That could lead to a collapse of the US healthcare system.

Another sign is the potential collapse of the housing market.

US Mortgage delinquency chart.

Even CEOs of major companies are telling government to stop the spread of Covid-19.

Perhaps the most difficult debate to watch from Spain is Trump’s push to re-open schools. Here is Sec’t of Education Betsy DeVos making the case to reopen schools no matter what.

Secretary of Education Betsy DeVos argues for schools to reopen.

It is a topic for which there are few data and fewer studies, so the debates are largely emotional because the trade-offs are unclear. The stakes couldn’t be higher with children’s well-being at risk whether they go to school or not.

Proponents of opening may want to take a look, however, at the second wave of Covid-19 infections in Israel.

On Tuesday, in testimony to the Israeli parliament, Udi Kliner, [Israeli public health chief Siegal] Sadetzki’s deputy, reported that schools—not restaurants or gyms—turned out to be the country’s worst mega-infectors.

The Daily Beast, “‘The Second Wave’ of COVID Hits Israel Like a Tsunami,” 10 July 2020.

You’ll be happy to know that Ana told me about a paella restaurant in Barcelona, near the Arc de Trionf. My friend and I didn’t have to travel to Sitges. Last night, we shared a traditional paella valenciana al fresco right in town. Covid-19 may have derailed my travel plans, but it opened my eyes to all the possibilities, culinary and otherwise, within walking distance of home.