20 September 2020 – Sunday – #113

It was fish on the menu last week. Brad had a mid-week hankering for sushi, so we walked a few blocks down Carrer del Bruc to Sun Taka for my first sushi meal in Barcelona. Didn’t have room for the sea urchin–I didn’t even realize it was the season already–but did try raw scallops the first time. I’ll be back for both.

Then yesterday I found myself in Girona. With fresh memories of Girona after our trip a couple weeks ago, Brad and I played tour guide for our Catalan friends Joanmi and Francesc. This trip was by car instead of train and took about the same time door-to-door. We viewed the Barceloninan landscape artist Modest Urgell and other Catalan artists at the Museu d’Art de Girona, and then descended to L’Estrella del Mar where Joanmi and Francesc selected almuerzo from the fresh catch.

Fresh catch at L’Estrella del Mar in Girona.

Joanmi told me he considered the restaurant typical for a good fish restaurant. That convinced me never to be a food critic because the place seemed like a great catch to me. I must be adjusting after five years dining in New York where this large a meal with this quality food prepared this well would cost 2x – 3x more, and still wouldn’t be nearly as fresh.

All this is by way of saying that, notwithstanding my mother’s reports about Spain from the US press she reads, dining and travel in Catalonia feel safe. In fact, here’s a picture of how the Covid-19 situation in all of Spain has improved in the past week.

Number of new Covid-19 cases and Re in Spain (source COVID-19 Re)

Spain’s post-lockdown Covid-19 cases increased more than anywhere else in Europe. I’m repeating myself when I write that this has been due primarily to bad Covid-19 outbreaks in three regions, Madrid, Murcia, and The Basque Country. The graphs above looked bad for Spain until the last week when trends started going the right way.

The Murcia government still doesn’t seem to have a handle on the health situation, but at least Madrid finally ordered, or might have ordered, new Covid-19 restrictions on Friday. I write might have ordered because the conservative government in Madrid gave the health director’s new restrictions a less than resounding endorsement.

Before I dive into Spanish politics, though, I note that Catalonia’s Covid-19 cases also went up after the lockdown, but leveled off quickly when public health authorities here put a few restrictions in place. Here’s a graph showing how Catalonia is managing Covid-19.

Outbreak risk and Re for Catalonia (source: Catalan News).

The Covid-19 effective reproduction rate Re (yellow bars above) went up the last two weeks of June, leveled off for a couple weeks, has been declining since mid-July, and has been less that 1.0 since the beginning of this month.

In some ways, Spain looks like the US. I can say Covid-19 is bad in both countries, but I also have to qualify where it’s bad for both countries. For Spain, I have to say it’s not bad in most places, but it’s really bad in Madrid and Murcia. For the US, I have to say it’s not bad in most places, but it’s really bad in North and South Dakota, Arkansas, Wisconsin, and Utah.

On the drive back from Girona, I quizzed Joanmi about the Spanish government and its Covid-19 response. Why is Madrid so different from Catalonia? Have Spain and the US had poor Covid-19 responses (Spain’s response relative to the EU, the US response relative to the world) because they share similar public health organizational structure? This turned out to be a good way to fill up an hour long road trip and I’m not going to bore you with the details.

The long and short of our conversation is that, yes, both Spain and the US have decentralized public health. In Spain, public health is managed at the regional level (there are 17 regions with, as far as I know, 17 different public health authorities). In the US, public health is managed at the state and territorial level. Both Spain and the US have central government public health authorities whose role is to coordinate the local authorities. That’s where public health similarities end.

The big difference is that, while Spain has a central public health authority, the authority has no resources. As Joanmi put it, Spain’s central public health organization consists of a minister and the receptionist who answers the phone. The US, on the other hand, had a world-class public health organization in the CDC, an organization that Trump has downsized and stripped of authority as he and his son-in-law dictated a free market response rather than a public health response to the pandemic.

Kushner, seated at the head of the conference table, in a chair taller than all the others, was quick to strike a confrontational tone. “The federal government is not going to lead this response,” he announced. “It’s up to the states to figure out what they want to do.”

Vanity Fair, “‘That’s Their Problem’: How Jared Kushner Let the Markets Decide America’s COVID-19 Fate,” 17 September 2020.

Joanmi also noted that the German government, which has a similar public health structure to Spain, had an effective Covid-19 response because Germany’s federal public health authority has the resources and credibility to coordinate German regions. Completely centralizing public health doesn’t seem to work. France and its centralized government structure performed about as poorly as Spain

But there’s something else interesting going on that Joanmi and I didn’t talk about, something that’s transcending comparative public health.

Covid-19 cases are becoming less deadly. Below is a graph of Case Fatality Rates (CFRs) for Spain and the US. The same thing is happening almost everywhere. Fewer people who get Covid-19 are dying. That’s a great thing, but why is it happening?

Case Fatality Rate (CFR) for Spain and US (source: Our World in Data)

Dr. Monica Gandhi from UCSF gives the long answer.

Dr. Monica Gandhi from UCSF on declining Covid-19 death rates (starts around 32:30).

If you don’t have 15-20 minutes for Dr. Gandhi’s excellent presentation, I’ve summarized it on my Twitter feed.

Summary of Dr. Ganhi’s presentation on declining Covid-19 deaths.

If you don’t have time for that, here’s the spoiler: masks. But it’s important to understand why, so watch the video or read through the summary to understand why Dr. Redfield at the CDC was correct when he said that masks may be more effective than vaccines at stopping Covid-19, and why Trump is killing people when he contradicts Redfield.

I’m going to sign off this week with a reminder of what competent Covid-19 advice looks like.

Christian Drosten discusses Covid-19 outbreaks likely this fall and winter.

It’s going to be long year before we get vaccines, so wear a mask, keep your distance, wash your hands, and enjoy fresh fish!

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