Josep Maria Argimon: "The covid will stay forever"

BarcelonaThe secretary of Public Health and director of the Institut Català de la Salut (ICS, the Catalan Institute for Public Health), Josep Maria Argimon, took the lead in the strategy to deal with the coronavirus at the end of July last year. Six months later, he takes stock of the various aspects linked to the covid pandemic.

Mortality is skyrocketing, with half a thousand victims a week. Was allowing Christmas meetings a mistake?

— I think we also needed the Christmas meetings from an emotional point of view, from the point of view of emotional wellbeing, so I wouldn't dare say that. And it is true that after Christmas covid increased, but we have continued to grow at the same rate since the 8th or 10th of December, 2%. What we all feared is that this somewhat devilish calendar of Christmas, New Year's Eve and the Epiphany, five days apart, could be an explosion of cases, which has not exactly happened. We have continued to grow until the 13th or 14th at this rate of 2%.

You say that many criteria must be combined, one of which is emotional health. Will all the countries of the world, including Catalonia, face a mental health pandemic at some point?

— I think so, it will be a fourth or fifth wave, but it will come. This pandemic will not go unnoticed from a social and everyday point of view. Now we are suffering a lot in terms of infected people, deaths, people admitted to ICUs, but this will leave us after-effects, for example in the emotional sense. Because there are a lot of people who are having a very bad time and have lost their jobs. We are seeing riots in the Netherlands, in other countries, and here we have also had some disturbances at some point, which means that there is tension, and that is normal. There is unrest and one day or another it will have to come out. And, afterwards, this can lead to a society that is frightened, fearful, that asks for more security over freedom, and this is a path that is a breeding ground for extremism and fascism.

It seems that the British variant is 30% more contagious, but is it more dangerous?

— No, it is very important to make this clear. It is not more dangerous. Another question we all have is whether the vaccine is effective against the variant. Yes, it is effective. We also monitor it from the epidemiological point of view and to know what we have to face. But if I am infected with the British variant, I have to do the same as if I am infected with the most common variant. If I am a close contact of a British variant, quarantine, and if unfortunately I have to be admitted to hospital, I will be given the same treatment. What is true is that it is more infective, it is transmitted more and therefore we will expect more cases.

Dr. Tomàs Pumarola told us that this variant currently affects 8% of the population in Barcelona. At the end of March, could it be the predominant one in Catalonia?

— Certainly, because here there are two variables that have to be looked at: transmissibility, which is this 30%, and prevalence. That is, when you have this higher transmissibility, we will have more and more frequency of this variant and there will come a time when it will surely be a predominant variant because it has advantages over the current one, which is that it is more transmissible and, therefore, it will stay.

Will covid stay forever? Will we have to get used to the fact that, in the same way that we know the flu, we have known another disease called covid - and that somehow we will have to manage it?

— Exactly. I think it's a disease that will obviously stay. When we talk about herd immunity, what we mean is that the virus will no longer be so comfortable among us, because there will be many people immunized, either because they have passed the disease or because they are vaccinated. And it won't jump around so easily anymore. If you're vaccinated and I'm vaccinated, it's difficult for it to jump, isn't it? But there will always be strongholds and therefore there will be outbreaks, there will be isolated diseases and in some cases it may still be serious, obviously.

Is there a direct relationship between reduced mobility and covid mortality?

— Clearly, yes. We also have to see if this can be the only measure, because we are talking about a disease and a problem that does not last a fortnight. Here, when this stricter containment was carried out (we are talking about the end of March and the beginning of April), during those four or five weeks, everyone thought that there would be a second wave, because it was the coronavirus' turn to do it, in October or November. Everybody pretty much thought that, and then we would get over it, and so it was all accepted as okay. Now, when we have all been on the same boat for a year and we have a few months on the horizon, it is more difficult to accept these measures, and also what we were saying: we have to look at this emotional well-being and mental health, as well as economic health, which affect the population.

Therefore, do decisions have to be taken crudely with a unit of measurement that is either a percentage of the GDP - or a number of deaths?

— Yes, but like it or not, I wouldn't contrast the two either. The two are related and are pillars of individual and social well-being. Contrasting them is not good either. That is why, sometimes, not only me, but also the Minister, when we are in meetings we make one criterion prevail, which is the criterion of health, which is clear. But there are others. And this is precisely public health, which has to look at what goes far beyond what is properly the physical or the mental health of citizens. You are looking at exactly what are the health determinants and the social and economic determinants that affect health.

In fact, you said it very clearly: if we were Germany we would close things up more, because we could give more support to the economy.

— That is very clear to me. If we were Germany we would have been able to compensate and subsidize businesses that have had to close and that are having a very hard time. And there are many people and many families who depend on these businesses. Therefore, although everyone wants to work, if at least part of your income is guaranteed, we would have been able to make longer closures. And we would surely have managed the pandemic better.

The management in Catalonia is very different from the management in Madrid, and obviously there are many factors that intervene in this pandemic and many factors that intervene in mortality, but our data tell us that there is a higher mortality rate in Madrid in the whole cycle of the pandemic. Do you share these data?

— Yes, I agree with these data. I have sometimes made statements along these lines. That is, if we were to apply the mortality rates that Madrid has to Catalonia, we would have around 7,000 more deaths; I am telling you this from memory. But yes, I agree with these data and it is a decision that everyone has to make, a management decision. It is not the only country that has taken this type of decision. Sweden is another one. And at the beginning there were, so to say, supporters of Sweden who later had some problems. It is the Nordic country that has perhaps handled it the worst, from the point of view of data. Perhaps they can look at other variables where they have had better results. Or let's also remember Boris Johnson's government at the beginning, which is neither Bolsonaro nor Trump, I'm not comparing him in this sense. His former health minister talked about natural immunity: it's a virus; therefore, let it infect. The problem they had is that it's a virus that infects - but leaves some people very sick.

Were you expecting such harsh after-effects on people's health, such long after-effects, initially?

— No, clearly not. At first, and I have said this more than once, we were in denial. I am not talking about when I was still in China, because in China it is very complicated to know the data - but in Italy. And we all have colleagues, friends who work and live in Italy. Therefore, we could more or less know what was going on in Lombardy and we were in a certain denial, except perhaps Dr. Oriol Mitjà.

Have you said that you will maintain the current restrictions in Catalonia beyond 7 February?

— No, I have said that this is my opinion and this is a choral decision where evidently mine is one of the opinions, but neither the only one nor the most important or the predominant one.

Does the predominant opinion mean that there is a natural internal tension between economics and health, when it comes to taking decisions?

— There has to be this tension. As I said before, both are very important. Sometimes we also say that this tension has been magnified a little within the Government itself. Here I have to say one thing: I was asked about it and I said "Look, at some point, it's even entertaining". I said this to take the heat off something that is true, which is that measures have been taken. On 21 December we took a very drastic and painful measure for the catering sector, which was to limit opening hours. On January 7th, for all sports competitions. We do not have federated sports competitions, but we are not talking about professionals - but about our sons, daughters, young people... Not all communities have it. That is to say, we have taken many measures that are hard, drastic, trying to control this pandemic as best as possible. We must have been wrong, we must have been right some other times, but what I want to say is that these tensions are greatly magnified, but decisions have been taken and this must also be a point in favour of the Government.

At this time, personally, would you be in favour of closing borders, as Portugal has done?

— What I think is very necessary is to limit mobility. When the European Union, for example, talks about essential travel, it is very complicated to decide what is essential. But what I believe is necessary is to limit mobility as much as possible. We cannot close borders in Catalonia at the moment.

At the moment we are in a complicated situation, which is this British variant that is approaching. We have many ICU beds occupied, a rather fragile situation.

— We are in a fragile situation, you have got the word right. Why? Because at the moment we have over 700 people in ICUs, almost 2,900-odd people admitted, and although the curve is bending tentatively, we need it to decrease for many weeks. If we continue to decrease at this rate, on February 14, that is, in about 15 or 20 days, more or less, we would be at about 2,000 cases a day. Today we're at 3,000, so we still have time to reach a balance of inflows and outflows in ICUs, which is 1,000 infected people a day, about 7,000 a week. And when we reach this point, we will still have to wait a few more weeks for the people who are in intensive care units to be able to leave, go back to the wards or go home. Because we already know that a person who enters an ICU is admitted for weeks, not days.

So we have a narrow margin.

— We have no margin. Because, of course, if you reduce to 60 - I put this figure to put any figure - or to 500 and then go up again, you start from 500. In this third wave, in one month we have admitted 300 patients in ICUs and in one week we have admitted 100. If you start from 500, you can quickly find yourself at 800 in three or four weeks. The difference between the second and the third wave is that the second wave started with 140 people admitted in ICUs, and the third wave started with 320. The long weekend of the 6th and 8th of December came - and from there we started to go up again, but we began to increase with 320 people admitted in ICUs.

Let's talk about vaccines. You said a moment ago that it seems that vaccines work for all the strains that we are detecting.

— At the moment, yes.

I wanted to go precisely to this "at the moment", because scientific truths are transitory.

— All of them.

So, what do you mean with "at the moment"? Do you mean that there may be a new mutation, or that you are afraid that the Brazilian variant, for example, will not respond as well as the British one?

— Well, all of this has to be looked at, because for example with some of these variants Moderna has said that their vaccine is effective. It has certainly been looked at in vitro, and from this point of view, like everything else, we still have to take it with a grain of salt. At the moment we have not detected these strains. There is a South African one, if I remember correctly, but not in Catalonia. We do not expect this to increase, at the moment. We always say "at the moment". What happens is that this virus has mutated from the beginning. It has more than 4,000 mutations, and that's normal, that's what viruses do: when they jump, they change. When there is a fairly important mutation or when several mutations are added, we talk about new variants. There are variants that have no or very little epidemiological importance - and others that do. The virus will continue to mutate because now we will put it under very important pressure - I am talking globally, worldwide - because we will vaccinate. The virus will start to see that it is not so comfortably installed in our homes. It is a virus that is very adapted to us, that has a significant mortality rate, 1.5%, very significant, but not enough for it to die in the attempt. Therefore, it jumps, it infects and it adapts. When people start to be vaccinated, immunized people, it will not jump so easily and, therefore, its way of surviving will be to change, to mutate, and some of these mutations may be epidemiologically more complicated. Certainly, and we also have to say this about vaccines, changing the instruction book of a vaccine is relatively simple: about six or eight weeks, so if any of these variants have to be changed, this instruction book can be changed.

Do you think that the majority of the population could be vaccinated between summer and autumn?

— Between summer and autumn, if we have vaccine availability, yes. We are always talking about the availability of vaccines. The new minister continued to maintain this summer date. Two million doses would have to arrive every month.

Do they tell you that these two million doses will arrive every month?

— No, no. We know that we are committed to 60,000 doses a week from Pfizer for 12 weeks. This is what we have committed to. Plus Moderna, which we have committed to 5,000-odd units and which have already been administered, and 8,000 that are due to arrive this week, hopefully on Monday or Tuesday. We are committed to some 84,000 more doses of Moderna throughout the month of February, but we don't know if they will come in instalments of 20,000 each week, or if they will come all at once,. And then we have to see how many doses arrive from AstraZeneca, which says that what it had committed to for the first quarter has to be reduced to 60%. And we know nothing about this contract, which is unacceptable. This is supposed to be a democratic, participatory society, to which we all contribute with our taxes. I believe that the European Commission cannot allow itself to sign contracts with confidentiality clauses, which then means that we cannot know anything. This is not acceptable.

We have explained this a lot, and the only thing we know is that the EU says it will not allow the material to be exported. Do you think this is feasible?

— Yes, you have said that, I hope so, even though this is not my field. It is true that, when you negotiate, you have to negotiate with all the tools, all the tools you have, and obviously first you start by explaining how you can fix the situation and then everything will have to be put on the table. That is to say, "let's not get our fingers caught, neither us nor you". Maybe it's a bit too colloquial of an expression, but that's the way it is.

What do you think of the people, including politicians, who have been known to have jumped the vaccine queues? Should they be punished?

— Well, in principle I always have to think that everything is done in good faith. I say it as clearly as that. I don't judge, first of all. The medical profession does not judge. It listens, looks and makes diagnoses and recommendations. Also because everyone probably thought that we were starting a vaccination campaign and that this would be.... Well, it is when we have seen that perhaps vaccines are lacking that people have reacted. What I can tell you is that not giving second doses does not make sense. That is, if you have vaccinated, the second dose has to be given. In the end, everyone has to be vaccinated. The sanction has to be a sanction. If it is a politician, a more political sanction, and here it is no longer up to me to say what it should be.

Will the vaccination process make use of large spaces, such as museums?

— I want to use museums at some point for a very simple reason: I believe that culture has been a key element, especially in the first stage of the pandemic. People who had to stay at home listened to music, watched Netflix, read books or went out on the balcony to sing. So culture is part of the solution, but unfortunately culture doesn't mobilize a lot of masses. So a museum for us is important. Also, as the Catalan Health Institute, we have projects for the emotional recovery of professionals, such as Recuperart-19, which we have done in 14 museums, including the MNAC, or Arts in Health, which has not been around since the beginning of covid, but for three years. I believe that art and culture help health, and I think there will be an understanding. We also have other spaces, but I think we will use museums to call the attention of citizens to the fact that we have to get vaccinated.

Would it be symbolic?

— This is my opinion.

Your opinion.

— Yes, there are always many opinions in the department. Don't laugh. Now we are thinking about Lleida, where we have a center that is next to a sports pavilion and the question could be raised. We are not saying this either because we have not spoken to the City Council yet, but yes, there would be some spaces that could be regular and others that would be more symbolic, as you said.

Can this pandemic, in order to get something positive out of it, help to give prestige to scientific knowledge in our society?

— Look, we will get many positive things out of it: the first, for example, is that all the research has been open-ended.

Internationally.

— Unlike the contracts clauses, with research, on the 10th the genome is published so that everyone can start working. You cede the copyright to the journals, you cede everything to them, even your soul for what may happen in another life, all the information. This is a key point. And you were talking earlier about Professor Pumerola's sequencing. When we ask the four big centres that can now sequence, we are thinking about sequencing not only for covid but beyond it, in a manner more characteristic of 21st century health. In May we understood that we needed a different microbiological follow-up and a different monitoring and, therefore, we used Feder funds to carry out a project and a sequencing platform that goes beyond what a research centre can be.