14 April 2020 – Tuesday – #30

I might have to become a healthcare worker to get PrEP in Spain.

“We are seeing few cases of HIV-positive people with severe COVID-19. This is surprising because the immune system of an HIV-positive person has similarities to that of older people who do have severe cases of COVID-19. Furthermore, there is evidence from in vitro studies that supports Truvada can have an immunomodulatory effect.”

Dr. Jose Arribas, Research Director, HIV and infectious diseases, La Paz Hospital, Madrid

I’ve been using Truvada for about five years. It may seem weird that PrEP (Pre-Exposure Prophylaxis) for HIV would have anything to do with Covid-19, but it doesn’t seem weird to me. I noted to my US primary care doctor that my incidence of cold sores dropped to almost zero after I started PrEP. Not that my cold sore experience means much statistically, but I’ve been wondering for a while whether PrEP is protecting me from more viruses than HIV.

The reason I make a joke about becoming a healthcare worker to get PrEP in Spain is that the most frustrating thing living here has been obtaining PrEP. Note to the Spanish healthcare system: make PrEP easier to obtain without becoming a healthcare worker on the front lines of the Covid-19 response.

I’ve seen four doctors at my current healthcare provider, all of whom understand that I want Truvada (or, even better Discovey, which isn’t available here yet), but none of whom have figured out how I obtain it through the Sanitas system. I tried taking a Truvada prescription to a pharmacy. The pharmacies had no idea what to do with it. This surprised me because HIV+ patients use Truvada, too, and Sanitas must provide Truvada to them. But how? Through the public health system?

In theory, some day I will be able to obtain PrEP for free through BCN Checkpoint, the local gay-oriented public health service. That’s possible after I sign up for the CatSalud public health system. Okay, that seems simple. But let me give you a taste of Spanish bureaucracy.

According to Felix, my incredibly helpful contact at BCN Checkpoint, I can’t sign up for CatSalud until three months after I obtained my empadronamiento, the Spanish registration that says I live in Barcelona. So first I needed an apartment. After I got an apartment, I got my enpadronamiento. Now I can’t apply for CatSalud until next month and I don’t think my application will be at the top of the CatSalud processing queue after the lockdown.

In the meantime, I have found online PrEP providers that cost about US$60 per month. I don’t mind the cost, but delivery has been problematic. The first delivery took about 20 days, the second 38 days. Needless to say, I’ve missed some doses. It doesn’t matter right now in isolation, but it would be nice not to have to worry about how to obtain PrEP here.

So, that’s why I say it might be easier to get PrEP if I just become a healthcare worker.

When Covid-19 came knocking, both Sweden and South Dakota preferred their economy and individual rights to the collective public health good of a lockdown. For those making the argument that “the cure is worse than the disease,” there are now data on the cost side. The pandemic is far enough along to measure the incremental loss of life when a government chooses to ignore the pandemic.

Here’s a mortality comparison for Sweden versus its Scandinavian neighbors.

Sweden has about double the mortality per capita of its close neighbors. This seems like a reasonable comparison because the four Scandinavian countries have similar cultures and healthcare systems. None of these countries have saturated their healthcare systems. Sweden has adjusted its Covid-19 policies recently, but it appears that the cost of keeping the Swedish economy going rather than locking down is a doubling of its Covid-19 mortality.

If Sweden saturates its healthcare system, it’s likely that its per capita mortality would be more than double its neighbors’. Countries that have saturated their healthcare systems, like Spain and Italy, have roughly 6x the per capital mortality of countries that have not, like Germany. That suggests that lack of an early lockdown costs about 2x mortality and the cost of a lockdown that’s so late the country’s healthcare system becomes overwhelmed is another 3x mortality.

To understand the cost-benefit properly of Covid-19, we’ll need Q2 economic statistics for Sweden and its neighbors to show the benefit side. My guess is that Sweden will outperform its neighbors, but not by much. Sweden’s economy is tied to the rest of Europe and the world. That will at least damp Sweden’s performance. Also, Swedish workers are adopting aspects of lockdown on their own. The open question is whether countries that don’t lockdown escape the downturn created when their neighbors and other countries lockdown. I suspect the effects of continental and global economic performance outweigh the local effort, especially where economies share a currency. This is where a coordinated worldwide response would pay off.

South Dakota has no stay-in-place orders as of yesterday. Here’s a comparison of per capital Covid-19 confirmed cases and deaths for South Dakota and neighboring states to the south and north.

	Confirmed Covid-19 Cases per capita	Covid-19 Deaths per capita
South Dakota	1.0 per 100,000	7 per million
Nebraska	0.5 per 100,00	9 per million
North Dakota	0.4 per 100,000	10 per million

The absolute number of deaths so far is so small that the death statistics don’t seem useful. Per capita mortality rates will be clearer in a few weeks when the number of deaths in each state are in the dozens. The confirmed cases statistics probably are not measured as well as the death statistics, but there are hundreds of confirmed cases, so the statistics are more useful.

Like Sweden with double the per-capita mortality of its country neighbors, South Dakota has double the per-capita confirmed cases of its state neighbors. As the per capita deaths increase, I expect South Dakota deaths will follow its confirmed cases and run about double its neighbors. So here is a second case showing the cost of no Covid-19 distancing measures is a doubling of mortality (in the absence of a saturated healthcare system).

A Covid-19 outbreak at a Sioux Falls pork processing plant has pitted Mayor Paul TenHaken, who is requesting a state-wide stay-in-place order, against South Dakota Governor Kristi Noem. Ironically, the Republican governor is going full Trump. Rather than ordering social distancing, she has announced the state will be the first to run a state-wide hydroxychloroquine trial. It looks like South Dakota will be providing the rest of us statistics for how a full Trumpian Covid-19 response performs. If you read yesterday’s entry about hydroxychloroquine, you know there is no good evidence hydroxychloroqine helps with Covid-19 and good evidence that its use can be risky. Good luck, South Dakota!

Speaking of Trump, state governors have taken Covid-19 matters into their own hands, forming state coalitions to coordinate the end of state lockdowns. Of course, Trump claims absolute authority to order citizens back to work. The governors’ actions show the degree to which Trump has lost credibility with state governments due to his inept management. Sadly, as noted above, states and countries would benefit from Covid-19 policy coordination, but Trump has created a situation where the political stakes for him of reviving the US economy differ from the reality governors face to keep their citizens safe.

Parenthetically, Covid-19 breaks the entire Trump Make America Great Again political brand. MAGA assumes there is some past version of America that Americans want to revive. Covid-19 forces America to look different from before. There is no way back to what anyone might have thought of as normal.

I’m not a tea drinker, but my Mom is. She reminded me on our call yesterday when she mentioned she can’t order first flush Darjeeling Tea. Actually, I am the one who orders it for my Mom, but no need to stand on ceremony. Covid-19 in India is pitting public health against the well being of the tea industry which has lost its “champagne” first flush harvest this year and probably will lose its second flush harvest, too.

I tried first flush tea once when the father of an employee, a peppy software engineer named Himanshu, showed up at the office with samples from his tea garden. We spent an hour learning about the flavors. It was as interesting as a wine tasting, but without the buzz. I said I would visit, but I haven’t got to India yet. I wonder when that will happen.

It seems like everyone I talk to is tired of being cooped up inside. When they aren’t having anxiety from looking at four walls, friends are having travel fantasies. My current travel fantasy is to walk down to the Mediterranean and look towards Algeria. What’s yours?