The Martínez-González brothers lived the onslaught of the first wave of Covid-19 in Spain in different trenches of the same front. Miguel Ángel, as epidemiologist and professor of Public Health at the University of Navarra and visiting professor at Harvard University; Julio, as an internist at the Regional University Hospital of Malaga. From their experiences, their research and their cross reflections, the Healing on fire [Planeta], a book that they predict as “controversial” but necessary to rescue from oblivion the outstanding debts with health workers and patients in the first months of the pandemic.
Indeed, the work has something of a time capsule: it was “practically written” in August and revised for publication in the fall as a warning of a third wave. “We would have been like fortune-tellers,” Julio jokes. Its pages are unrelated to discussions of coronavirus variants or vaccine combinations. Rather, they take us back to dark days of hospital collapse, PPE with garbage bags, soldiers sterilizing the deserted streets with hoses, daily reports of Fernando Simón responded with virulent memes on WhatsApp, and the Ice Palace morgue. Everything that pandemic fatigue and euphoria from a summer without a mask conveniently compels us to ignore.
How do you assess the evolution of the pandemic since the time of the last writing of the book, December 2020, and now?
Julio: The key is in what was not done at the end of 2020. Remarkably, the Ministry of Health did not follow the recommendations it had given itself. And the third wave came.
Miguel Ángel: I published an opinion piece shortly before Christmas warning about the Thanksgiving experience in the United States. And we knew that we would have more family reunions still than the Americans. We said a brutal third wave was coming, and it did. The recommendation of our health authorities in mid-December should have been much clearer and more rigid. They have not been up to the task. But of course, what I say reaches some, what Fernando Simón says reaches the whole country.
There are two key elements that they advocated in the book that have managed to turn the tide: antigen tests and vaccines.
J .: Well, I really miss antigen tests. They have been doing them every three days to footballers, but for those of us who were on the floor treating patients, I can attest that they have never been done. In the entire hospital they have been done twice, only when there have been outbreaks.
MA: They are elements that cannot be compared. Vaccination is what is really changing the trend, but the pace was maddeningly slow in the first few months. Now it is picking up speed, but we are not going to reach the goals that they had proposed to vaccinate before the summer and that are necessary. The longer it takes to vaccinate, the more the virus will circulate and the greater the chances that a variant will emerge that renders the vaccine useless, thus, the solution is over.
How has the profile of the person admitted by Covid-19 changed in Spain?
J .: The vaccination campaign has been very good when starting to vaccinate in nursing homes. Cases have dropped dramatically. That elderly population no longer enters. When the elderly enter, you start to see deniers. You say, “Pitcher soul, why haven’t you been vaccinated?” “Is that a brother-in-law told me …”. Now young and seriously ill patients, who have not been offered the vaccine, draw attention. But also, in the income of 40 people, the one who is not obese, is hypertensive or diabetic. You have to be consistent and behave like rational people, have healthy habits as Miguel Ángel tells us.
MA: Perhaps little has been said about the importance of healthy eating and lifestyle habits. The percentage of hypertensive people in Spain is very high, also that of obese and type 2 diabetics. All have a higher risk of becoming ill and of having a serious clinical case. Vitamin D is being studied as protective, especially in people who suffer from deficits, but it does not act alone. That is why we are talking about the overall diet pattern: we have been able to show, with the study by the University of Navarra, that the Mediterranean diet substantially reduces the risk of infection.
And how has the treatment evolved in these months?
J .: What we do now when we admit a patient is to put corticosteroids to reduce inflammation and directly anticoagulants. When a patient seems to evolve well and suddenly worsens, something very common with coronavirus, the first thing we do is an Angiotac to rule out pulmonary thromboembolism, which causes respiratory failure very quickly. The incidence is variable but very high, between 5% and 10% of cases. Not a point of comparison with the risk of thrombi from some vaccines.
Do they perceive a ‘collective forgetting’ mentality about what happened in the first wave of Covid, a willingness to leave it behind as soon as possible?
J .: Alfonso Guerra used to say that the worst defect of Spaniards is not envy but lack of memory. And he was absolutely right. We wrote this book so that what happened would be black on white. There is a subconscious and a political intention, more or less guided, to let it go, forget it and bury the problems.
MA: I think there is a certain pact of forgetfulness that is not good. There must be an absolutely independent audit of any governmental instance. Among those who requested it in August in the letter to The Lancet There were people who had been high positions of Public Health with the PP, with the PSOE or with the PNV. Seeing them all together encouraged me to write the book. All Spaniards have to know about this! Spain has always been in the shameful last places of the international rankings of how the pandemic has been managed, of how mortality has been made up, of health infections, of drop in GDP. It is difficult to accumulate so many calamities. The televisions related to the Government have sold us ‘Alice in Wonderland’ and they have been making jokes with Fernando Simón while there have never been so many funerals in Spain.
The obscurantism of those early days is what attracts the most attention now. The health workers were asked not to wear a mask to “not alarm.”
J .: I am a general internist, but I am ‘on loan’, like footballers, to the infectious area from the beginning. And there we celebrate May 29, the day on which the mask was finally established as mandatory in Spain. When on February 11 the Ministry of Health had already published the recommendation to use it. And all that so that in the middle of March they ask me not to wear the mask so as not to alarm the population? What are you telling me? The time came when I took out the sewing machine and made them at home, because they didn’t give them to you. Now that you see that they give them to the visitors, you say to yourself: “How we have progressed! What a waste!”
MA: Self-criticism has been lacking. I have wondered many times how many mistakes I would have made if I had been in the place of the person responsible for the Center for the Coordination of Health Alerts and Emergencies. You cannot ask anyone to be a prophet of a pandemic that no one knows about, what you can ask is that they know how to read. He should have read the recommendations of the World Health Organization, which said: “Test, test, test. No mass events.” Me, making self-criticism about those mistakes, I would leave. Bullfighter shame. You have to have credibility. And having it before health professionals is very difficult. You have to arouse admiration. Someone without publications, without an MIR specialty in Preventive Medicine and Public Health, which is what I have done, without a doctorate, what prestige does he have?
The professor of microbiology Ignacio López-Goñi commented on Fernando Simón that the epidemiologist does not have to replace the politician in press conferences, but rather be by his side to inform and supervise.
MA: This is very important. Ignacio is a great expert and a great friend, and he’s right. When someone has as much prestige as Anthony Fauci in the US, with more than a thousand publications and having advised six presidents, he can cough up Donald Trump and anyone. When someone does not have that pedestal, they end up being the voice of their master. I know what I’m saying is very hard. But someone like Valentín Fuster or Rafael Matesanz doesn’t care what the Prime Minister thinks of him. Someone like this can put politicians in the wrong direction so they don’t get off the scientific track. Who does not have that value, they put him in an orchestra led by a publicist. And I do not say more.